“Protect the NHS” has been a recurring message that has shaped the UK’s response to COVID-19. The danger that the pandemic could overwhelm the NHS has never been far out of sight. As we approach the five-day relaxation of restrictions for Christmas, the question of whether the NHS will be able to cope is as pertinent now as it was in March.
What has become apparent is that the major limit to treatment capacity is not the number of hospital beds, nor even the number of intensive care beds with ventilators, it is the number of appropriately skilled nurses available to provide care. The pandemic has exposed an achilles heel: a deficit in nursing.
This isn’t a new problem. Around 10% of positions for registered nurses in the NHS were vacant when the pandemic first hit. Analysis from the charity the Health Foundation has found that over the last ten years, NHS activity (the number of patients seen and care provided) has risen year on year, but without a corresponding rise in the nursing workforce.
Between 2010 and 2017, the number of nurses in the NHS barely changed. From 2017 to June 2020 there was a 4.8% rise, but the gap between amount of the work to do and nursing numbers has continued to widen. As the shortage of registered nurses persists, the NHS has employed larger numbers of support staff, such as nursing and healthcare assistants. In the past year, the growth in support staff has been twice that of registered nurses.
A dangerous situation
Research points to the risks of not having enough registered nurses on duty. A nine-country study from 2014 found that increasing a nurse’s workload by one patient increased the likelihood of a patient dying by 7%. And in our own research, my colleagues and I found that when staffing levels were lower, nurses in England were more likely to report that necessary care was left undone.
Further analysis, led by the University of Southampton, found that the amount of “care left undone” contributes to the risk of unexpected death among hospital patients. Also, hospitals relying on lower levels of registered nurses and higher levels of lesser-trained support staff have higher mortality rates.
The risks of low nursing numbers were highlighted by the Francis Inquiry in 2013. Reductions in nurse numbers – made in previous years to achieve short-term savings – had not taken into account the risks to patients. The inquiry revealed the lack of policy or standards on nurse staffing levels and recommended that national guidelines be developed, based on research. The National Institute for Health and Care Excellence (Nice) subsequently published guidelines on “safe staffing” in 2014.
The inquiry and the Nice guidelines succeeded in raising awareness of the need to have sufficient registered nurses on duty. When surveyed in 2017, three-quarters of chief nurses said that support from NHS boards for bolstering the nursing workforce had risen since the inquiry.
Still, unsafe staffing levels persisted in many NHS trusts, primarily as they were unable to recruit the registered nurses needed. Policy had succeeded in motivating a desire for safe staffing but had not created the investment in the nursing workforce needed to deliver it.
Plugging the gap
In December 2019, the UK government recognised the need to address this long-term nursing shortage. It pledged to increase the number of registered nurses in the NHS by 50,000 by 2024-25. But how feasible is this target?
Interest in nursing has increased; 23% more students have been accepted onto nursing courses in England in 2020 than in 2019. The number of applicants rose sharply after March 2020 – the profile of nursing having been potentially heightened by COVID-19.
But the UK’s domestic supply of nurses per head of population is well below the OECD average and is insufficient to meet demand. So the NHS relies on nurses from abroad to make up the difference. A third of nurses first entering the UK register in 2019-20 trained outside the UK. In total, 15% of the UK’s registered nurses trained elsewhere – more than double the OECD average.
To achieve the government’s target, the Health Foundation notes that England will need to be able to recruit an average of 5,000 nurses a year from outside the UK between now and 2025. With Brexit ending the free movement of labour to and from the EU, and COVID-19 causing travel disruptions for the foreseeable future, this will be challenging.
The Health Foundation also notes that increasing domestic supply is a must. To do this, we’ll need to increase university capacity and fix the lack of clinical placements for students, which are typical bottlenecks. The Council of the Deans of Health, which represents UK universities that teach nurses, has proposed offering simulation-based clinical experience – using lifelike virtual environments, mannequins, role-playing and trained actors to replicate treating real patients – as well as reducing the total clinical hours needed to qualify as a registered nurse (the required hours in the EU are double those needed to qualify in the US and Australia). We also need to look at expanding the faster two-year graduate entry programme.
Achieving net growth will also require lowering the number of nurses leaving the profession. Around 33,000 (10%) nurses exit the NHS each year, many citing “too much pressure” as the cause. Arguably a modest oversupply of nurses is what we should be aiming for, as this reduces the costs of high turnover and reliance on temporary cover.
Meeting the 50,000 target is a beginning, not an end. Setting a top-down target represents a political attempt to galvanise a system that has been failing for years to train and retain the nurses it needs, relying on one short-term fix after the next. COVID-19 has exposed a national deficit in nursing skills that will require longer-term vision, robust plans based on accurate data, and investment to resolve.
Jane Ball (as an employee of the University of Southampton) has received research funding from the Department of Health and Social Care to research safe staffing policy and the National Institute of Health Research to research the effect of staffing on outcomes. As a principal investigator, she currently receives EU Horizon 2020 funding to research the relationship between organisational factors (including staffing) and staff wellbeing. She is a coauthor of the Health Foundation report "Building the NHS Nursing Workforce in England". She is a member of the Royal College of Nursing.