Health and care workforce being hollowed out

New surveys from the Royal College of Nursing and Association of Directors of Adult Social Services have laid bare the fragility of the health and care system as we head into the closing weeks of the general election and crucial winter months. They highlight the fundamental lack of resilience in front line services which are running on empty.

The RCN survey covers over 8,000 nurses and health care assistants across the country. It finds that six out of 10 nurses say they cannot provide the level of care they want to patients, up from just over four in 10 a decade ago. In adult social care, the warning from directors of social services couldn’t be starker: nearly all (90 per cent) are concerned that they have insufficient capacity to deal with winter or the failure of a major care provider.

Lack of capacity

At the root of these concerns, is a lack of capacity. The latest data from NHS Improvement shows that the number of unfilled nursing posts in the NHS continues to rise. Mid-way through 2019-20, nursing vacancies stood at more than 44,000. The paradox is that the NHS workforce is growing, with more than 30,000 more full-time equivalent staff in 2018-19; the biggest annual increase this decade.

The problem is that growth has not kept pace with increased demand. This is particularly true of nursing; since 2010 the number of nurses employed in the NHS has increased by around 3 per cent, but the amount of care provided across the health service by more than a quarter. As the RCN survey shows, the result is that nurses feel under intense pressure and worry whether they can provide the quality of care they need and want to.

New research from the Health Foundation shows that there has been an effective “hollowing out” of the NHS workforce as increases in the numbers of doctors and clinical support staff are set against much lower growth in registered nurses. The number of nurses per doctor in the NHS is falling and the balance between registered nurses and support staff shifting.

The health service is increasingly having to rely on less-skilled clinical support staff to fill gaps in services when there aren’t enough nurses, raising questions of quality and safety. Skill mix changes can be positive if they reflect changes in patient need, and are underpinned by evidence-based policy, but these developments appear to be a largely unplanned response to the failure to train and recruit enough nurses in recent years.

The figures also show that, in response to a severe drop-off in the number of EU nurses coming to the UK there has been a significant ramping-up of nurses arriving from non-EU countries – notably India and the Philippines. But the number of internationally trained nurses joining the NMC register, remains a third down on pre-referendum levels.

While the NHS is experiencing significant staffing pressures, the issues in social care are if anything, even greater. Social care workforce shortages stand at around 122,000, with 1,100 people estimated to leave their job every day – an annual leave rate of almost a third and steadily rising. Registered nurse jobs in adult social care have decreased by 10,400, or 20 per cent, since 2012, and by 2 per cent between 2017-18 and 2018-19 alone.

The NHS and social care recruit from the same pool for many care-giving roles. As a major employer, typically providing better pay, terms and conditions, and career progression than social care can afford, as the NHS struggles to fill its shortages, it is having a significant impact on the social care workforce.

More needs to be done to support social care. Improving terms and conditions is fundamental but it comes with a price tag; matching pay increases in the NHS to support recruitment and retention, would cost £1.7bn by 2023-24. Improving the experience of current staff in the NHS, ensuring it is a good place to work and build a career, is a key plank of work on the NHS People Plan, but at the moment there is no similar focus from government on social care.

As with the NHS, alongside the reduction in nurses in social care, there has been a relative increase in less skilled-staff. The decline in nursing numbers could be related to recruitment and retention issues, ‘but also may be a result of some organisations creating “nursing assistant” roles to take on some tasks previously carried out by nurses’ (Skills for Care, 2019) – a similar issue as in the NHS.

England simply doesn’t train enough nurses. Earlier this year, analysis from the Health Foundation, King’s Fund and Nuffield Trust found that without action nursing shortages could double over the next five years. All three main political parties have promised to improve the situation and train more nurses, reforming the bursary.

The Conservatives headline is 50,000 more nurses, from a mix of around 30,000 new staff and around 20,000 fewer leaving. Labour talk of training 24,000 more nurses. This is positive – as at a minimum, the number of new nurse trainees needs to increase by 5,000 a year.

However, given how long it takes to train new staff, politicians also need to be honest with the public: for the foreseeable future the NHS and social care system will be very reliant on international workers to prevent staffing shortages from impacting on patient care and acting as a brake on ambitions to improve quality.