Royal College of Nursing (RCN) – Written evidence (FFF0062)
Public Services Committee Inquiry: Designing a Public Services Workforce Fit for the Future
1. Summary
1.1 The Royal College of Nursing (RCN) is the largest professional body and trade union for nursing staff in the world. The RCN represents around 465,000 members who are registered nurses, midwives, students, and nursing support workers, and make up a vital part of the UK’s public services workforce.
1.2 In order to ensure the nursing workforce is fit to deliver safe and effective care in the future, the RCN is clear that the UK Government must prioritize and be accountable for the delivery of a fully funded workforce plan to build a safe and efficient health and care system. Nursing staff will be unable to respond to the needs of the population now, and in the future, unless the workforce has the numbers, skills and conditions needed to ensure safe and effective patient care. The following paragraphs reflect the RCN’s responses to selected questions on education, training, digital technologies and public services workforce planning.
2 Question 1: It is difficult to predict accurately how the public services workforce will need to change in the long term, and yet it is necessary to prepare now for the future. What is an appropriate approach to long-term planning for workforce needs and demand in public services, and how should current training adapt, not just at the point of employees’ entry into the workforce but throughout their careers?
2.1 It is the RCN’s view that the UK Government should hold responsibility for health and care workforce assessment and planning in England and be transparent about methods for understanding and planning sufficient scale and complexity of workforce needed within the health and care system, and for population need. The RCN is clear that data on long-term workforce need should be centrally held and used by the UK Government to inform workforce planning. Legal accountability for the provision of sufficient workforce, and the production of strategy, should live with the Secretary of State for Health & Care.
2.2 The RCN is clear that the UK Government’s approach to long-term planning for workforce needs and demand in public health and care services must move to a more sustainable demand-led workforce planning model based on long-term population projections and changing population needs, to ensure that nursing workforce numbers and skills are able to meet the care needs of the population.
2.3 Publicly available data that shows a clear need for increased numbers in the nursing workforce should be used by the UK Government to determine the adequate number and mix of clinical staff required to provide safe and effective care that meets population need across sectors and geographies. National data such as Office for National Statistics (ONS) population figures and projections, if not already used by the UK Government, should be used centrally to determine the number of nurses that should be educated to meet long-term need. For example, modelling developed by the Health Foundation and the Institute for Fiscal Studies (IFS) projects that emergency admissions to hospitals could double over the next 15 years, as a result of an ageing population, and an increase in the number of people living with long-term health conditions. i
2.4 Current training must also be financially accessible in order to maximise the number of registered nurses that enter the workforce. To increase uptake and retention of undergraduate nursing students, it is the RCN’s view that further reforms to the way nursing higher education in England is funded should be introduced to remove financial barriers for prospective undergraduate nursing degree students. This includes reimbursing tuition fees,and/or forgiving current tuition debt for all nursing and midwifery students, as well as abolishing future self-funded tuition fees for all nursing and midwifery studentsii. Further to this, the RCN has consistently said that universal, living maintenance grants need to reflect actual student need in terms of living costs so students can focus on their studies without experiencing financial and emotional stressiii. Sustainable funding models must be put into place to allow this.
2.5 In terms of current training adapting throughout the careers of those working in health and care public service, training will need to be adapted as population needs change, to ensure the health and care workforce are equipped with the skills required to meet the health and care needs of all patients. There is a need for sustainable funding to support career development across the health and social care sector, to avoid any retraining being dependent on an individual employer.
2.6 Nursing preceptorship and clinical supervision programmes must be designed to provide a seamless transition for nurses as they adapt to provide care throughout their careers. Approaches to Continuing Professional Development (CPD) should also be based on a wider system approach which incorporates individuals professional need, and team and organisational requirements. Support for educator development should be a primary discussion in workforce development, and a recognised amount of clinical education and clinical academic posts should be agreed per capita head of staff as part of public services workforce planning.
3 Question 2: Conventional approaches to training have not enabled enough professionals to enter the public services workforce to meet demand. How might training change to maximise the number of public services professionals and improve their skills?
3.1 In the short-term, immediate and sustained growth is required in the primary domestic supply route to registered nursing – the undergraduate nursing degree – to tackle staffing vacancies within the nursing workforce. The RCN supports alternate routes into nursing to address the immediate and future supply problems that undermine safe and effective staffing. However, these alternative routes – such as the nursing degree apprenticeship - are not sufficient to solve workforce issues and ensure the workforce meets demand. The traditional three-year university route provides the necessary scale and speed of growth required. In addition, there are a number of issues holding back successful implementation of nursing degree apprenticeships in England, particularly with the increased pressure on staff and the system, to deliver high quality placements while receiving insufficient funding support through the apprenticeship levy. iv
3.2 Recently announced changes to the student loan fee repayment threshold risk making higher education degrees even less attractive to prospective nursing studentsv. The RCN is clear that there must be no financial barriers for anyone wanting to undertake a nursing degree. To increase uptake and retention of undergraduate nursing students, it is the RCN’s view that further reforms to the way nursing higher education in England is funded should be introduced. This includes reimbursing tuition fees, and/or forgiving current tuition debt for all nursing and midwifery students, as well as abolishing future self-funded tuition fees for all nursing and midwifery studentsvi. Further to this, the RCN has consistently said that universal, living maintenance grants need to reflect actual student need in terms of living costs so students can focus on their studies without experiencing financial and emotional stressvii.
3.3 Practice placements offered throughout the undergraduate nursing degree must be designed to give nursing students the best possible learning experience, and nursing staff responsible for providing mentorship throughout student placements must be supported through CPD to deliver a high-quality learning experience for student nurses. Nursing students are required to undertake 2300 placement hours across the duration of their degree, a significant amount of time which must be considered in terms of the workforce planning required to provide enough nurses, with the right skills, to support the next generation of nurses in their learning.
4 Question 4: How might the public sector become more attractive as an employer, particularly in comparison with the private sector? How might it become attractive enough to retain workers throughout their careers while maintaining a level of turnover that brings fresh ideas to organisations?
4.1 To ensure retention within the nursing profession significant issues regarding pay and working conditions must be addressed. For too many, salaries have not kept pace with continued increases to living costs - the impact of this on retention should not be underestimated. Registered nurses must receive a pay award that recognises the complexity of skill and responsibility nurses demonstrate, and which also recognises that the salaries nursing staff receive has not kept pace with increases in living costs over the last decadeviii. The RCN seeks an NHS Agenda for Change pay award for the nursing workforce that delivers an above inflation increase, and adequately rewards nursing staff fairly for the highly skilled safety critical work they do, and includes parity for members of the non-NHS nursing workforce.
4.2 Staffing shortages in nursing contribute to retention issues, absences and burnout. An RCN 2020 surveyix found that around a third (35%) of respondents in England said they would consider leaving the profession by the end of that year. Of the around 11,000 people who reported feeling this way: 62% said it was due to levels of pay; 44% said it was because of how staff have been treated during the pandemic; 43% said it was due to low staffing levels; and 37% said it was due to unsafe working conditionsx.
4.3 The RCN’s Workforce Standardsxi set out what must happen within workplaces to ensure the delivery of safe and effective care.
5 What are the consequences for inequalities of access to public services of failing to attract high-quality professionals to the public sector?
5.1 The RCN is calling for registered nurse executive leadership roles to be legislated for within health and care structures– including the new Integrated Care Boards (ICBs). However, current legislation requires the Clinical Commissioning Group (CCG) governing body to include at least one registered nurse within its membership, establishing a statutory commissioned role for nursing leaders in England. The current draft of the Health and Care Bill does not transfer this statutory role to ICBs and leaves it to ICSs to decide the wider ICB membership. The RCN is deeply concerned at this omission, which may result in a lack of nursing representation at board level, and the overall uneven representation of nursing across senior levels of the ICSs.
6 Question 6: How can providers of public services recruit a more diverse workforce? How should they improve their recruitment of BAME people, people with disabilities, older people and people who use public services and live in the communities that providers serve?
6.1 Providers of public services should improve the diversity of recruitment by ensuring that employers commit to supporting individuals involved in recruitment processes to constructively disrupt patterns of inequality in recruitment by building on the skills and knowledge that enables the identification and challenge of forms of prejudice and discrimination in recruitment and selectionxii. Employers must fully embed these roles into their processes, structure and culture. Providers must review policies and processes to determine how they reflect to embody the commitment to equality and diversityxiii.
6.2 Ethnic minority nursing staff in particular experience significant discrimination in the workplace, and at every stage of their career, from pre-registration education experiences through to the end of their careers, nurses from ethnic minority backgrounds experience the culminative impact of both subtle and covert disadvantage. The recent review of Ethnic Inequalities in healthcare considers a body of evidence which shows both International and Black nurses experiencing racism in the NHS workforce, and found that Black African nurses felt that their experience and knowledge in nursing were not respected, nurses perceived being ignoring by patients and their relatives as racism as they thought that it implied that Black nurses were incompetent and reported being prohibited from performing certain procedures and that the responsibilities they were allocated were a reflection of managers’ lack of confidence in Black African nurses.xiv
6.3 If providers of public services wish to recruit a more diverse workforce, urgent action must be taken to further understand the experiences of ethnic minority staff, staff with disabilities, and older people, and meaningful action must be taken to address inequalities in experiences across the nursing workforce, in order to make nursing a more attractive profession to people with a range of diverse backgrounds.
7 Question 9: Preventative and early intervention services can improve the ability of the public services workforce to respond to users’ needs. How might such services be embedded within any public services workforce strategy?
7.1 The RCN has consistently called for greater investment in prevention and early intervention services and highlighted the essential role that nursing plays in delivering these.xv The diverse range of services and settings nurses work in gives them a unique position to deliver prevention and early intervention support. However, they need the time, training and support to do this effectively and truly make every contact count. There is an incorrect assumption that these interventions – for example discussing smoking or weight management, happens as part of routine consultation and contact with health care professionals. However, staffing shortages, demand pressures and the fact that prevention is not consistently an explicit part of all health care service contracts means that this is not the case. Embedding prevention requires sufficient time, training and resources to support staff to deliver effective prevention advice and support, and must be an explicit component of all health care contracts commissioned.
7.2 Although the UK Government has stated its commitment to embedding a focus on prevention,xvi this has not been supported by sufficient action. Funding for local public health services which prevent ill health and improve health and wellbeing, including smoking cessation, weight management, sexual and reproductive health, school nursing and health visiting, has been cut by 24% compared to 2015/16.xvii Embedding prevention and early intervention across the health and care system will require cross-governmental leadership and strategy for improving health and wellbeing and reducing inequalities. Furthermore, robust data-driven assessments of population need must underpin workforce modelling. Adequate investment and funding must be available for prevention services, including an increased sustainable long term funding settlement for local public health services and investment to ensure that there is an appropriate workforce in place to deliver the prevention agenda.
8 Question 10: What have been the effects of the COVID-19 pandemic and Brexit on the public services workforce? Have these events created opportunities for workforce reform?
8.1 Prior to the pandemic, vacancies were already impacting the ability of the nursing workforce to deliver safe and effective carexviii. The COVID-19 pandemic has had a significant impact on the nursing workforce, further exposing existing workforce issues, and the scale of change required.
8.2 The 2021 RCN employment surveyxix - registered nurses, health care support workers, students and nursing associates working across all areas of health and social care – found that workload pressures and staff shortages have had a profound impact on nursing staff as the impact of Covid-19 has hit the profession. Three quarters of all respondents (74.1%) reported regularly working beyond their contracted hours at least once a week, and just over two thirds of respondents (67.6%) reported feeling too much pressure at work, which impacted on the quality of care they were able to providexx.
8.3 The RCN has raised concerns regarding the impact of the UK’s departure from the European Union for the health and care workforce and the impact on nursing staff’s ability to provide safe and effective carexxi. Since 2016, the number on the permanent register whose initial registration was in the EEA has declined year on year. Between 2020 and 2021 alone, there were almost 1,000 fewer professionals on the register in England, who trained in the EEA and only 2% of all new joiners to the register were from the EEA. From September 2020 to September 2021, there was an increase of almost 10,000 professionals from outside the EEA on the register in England and 24% of all new joiners in 2021 were from outside the EEAxxii. The health system in England is currently undertaking significant efforts to recruit international nurses to bolster the workforce in England, most notably from the Philippines and India, with 30,235 and 21,531 nurses on the Register respectively. As a matter of urgency, the UK Government must seek to introduce mutually beneficial memoranda of understanding (MoU) with counterpart governments, and their respective national nursing associations to govern ethical recruitment with countries. MoUs should be monitored by independent stakeholders to assure fair and full compliance by all partiesxxiii.
8.4 International recruitment should not be disproportionate or take place at the expense of appropriate education, development and investment in the domestic nursing workforce.
9 Question 15: To what extent is public services workforce planning managed better at regional, sub-regional and local levels, rather than at the national level, and what mechanisms might enable more effective devolution of workforce planning? How can the Government train workforces to deliver more effectively those public services that are coordinated at the national level?
9.1 On training workforces to more effectively deliver public services that are coordinated at the national level, the RCN is clear that the UK Government, and specifically, the Secretary of State for Health and Social Care, must be made legally accountable for health and care workforce assessment, planning and provision in England, also that actions for workforce supply are set out in a published plan based on an assessment of population demand, and includes actions to ensure the health and care workforce meets the numbers and skill-mix needed to meet workforce requirements. This duty should not be delegated to regional, sub- regional and local leaders unless clear remits are set at national level and overall responsibility is held by the UK Government.
9.2 The RCN calls for accountability for workforce planning and supply to be held by the Secretary of State for Health and Care as a legal duty. This should include a responsibility for the SoS to, at least once every two years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health and care services in England. The report should include an independently verified assessment of health, social care, and public health workforce numbers, and the projected workforce supply for the following five, ten and 20 years; and an independently verified assessment of future health, social care and public health workforce numbers based on the projected health and care needs of the population for the following five, ten and 20 years, consistent with the Office for Budget Responsibility long-term fiscal projections. The RCN is currently calling for this duty to be enshrined in law through the Health and Care Bill. Government has, to date, rejected accountability for workforce planning and supply in this Bill.
28 February 2022
i Institute for Fiscal Studies and the Health Foundation, Securing the future: funding health and social care to the 2030s: https://www.ifs.org.uk/uploads/publications/comms/R143_Chapter3.pdf
ii Royal College of Nursing, Joint union letter to the Secretary of State on student debt and the COVID-19 pandemic, May 2020: https://www.rcn.org.uk/professional-development/publications/joint-union-letter-to- the-secretary-of-state-on-student-debt-and-the-covid-19-pandemic-pub-009260
iii Royal College of Nursing, Fund our Future: https://www.rcn.org.uk/get-involved/campaign-with-us/student- funding-fund-our-future
iv Royal College of Nursing, RCN POSITION STATEMENT: Nursing apprenticeships, 2019: https://www.rcn.org.uk/about-us/our-influencing-work/policy-briefings/br-0319
v Department for Education, Press release: Fairer higher education system for students and taxpayers, 24 February 2022: https://www.gov.uk/government/news/fairer-higher-education-system-for-students-and- taxpayers
vi Royal College of Nursing, Joint union letter to the Secretary of State on student debt and the COVID-19 pandemic, May 2020: https://www.rcn.org.uk/professional-development/publications/joint-union-letter-to- the-secretary-of-state-on-student-debt-and-the-covid-19-pandemic-pub-009260
vii Royal College of Nursing, Fund our Future: https://www.rcn.org.uk/get-involved/campaign-with-us/student-
viii Royal College of Nursing, Fair Pay for Nursing: https://www.rcn.org.uk/get-involved/campaign-with-us/fair- pay-for-nursing
ix Royal College of Nursing, Building a Better Future for Nursing: RCN Members have their say, August 2020: https://www.rcn.org.uk/professional-development/publications/rcn-builiding-a-better-future-covid-pub- 009366
x Ibid
xi Royal College of Nursing, Nursing Workforce Standards, May 2021: https://www.rcn.org.uk/professional- development/publications/rcn-workforce-standards-uk-pub-009681
xii Royal College of Nursing, submission to the Commission on Racial and Ethnic Disparities call for evidence, 2021: https://www.rcn.org.uk/about-us/our-influencing-work/policy-briefings/conr-13320
xiii Ibid
xiv NHS Race and Health Observatory, Ethnic Inequalities in Healthcare: A Rapid Evidence Review, February 2022: https://www.nhsrho.org/wp-content/uploads/2022/02/RHO-Rapid-Review-Final-Report_v.7.pdf
xv Royal College of Nursing, submission to the Department of Health and Social Care and Cabinet Office
consultation on the Green Paper: ‘Advancing our health: prevention in the 2020s
xvi Health and Care Bill
xvii Health Foundation (2021) Public health grant allocations represent a 24% (£1bn) real terms cut compared to 2015/16
xviii Royal College of Nursing, Nursing workforce in crisis even before pandemic, reveals RCN report, February 2022: https://www.rcn.org.uk/news-and-events/news/uk-nursing-workforce-in-crisis-even-before- pandemic-070222
xix Royal College of Nursing, Employment Survey 2021, December 2021: https://www.rcn.org.uk/professional- development/publications/Employment-Survey-2021-uk-pub-010-075
xx Royal College of Nursing, Employment Survey 2021, December 2021: https://www.rcn.org.uk/professional- development/publications/Employment-Survey-2021-uk-pub-010-075
xxi The Royal College of Nursing, BREXIT: Royal College of Nursing priorities update – overview, 2020: https://www.rcn.org.uk/professional-development/publications/pub-009168
xxii Ibid
xxiii International Council of Nurses, Sustain and Retain in 2022 and beyond: https://www.icn.ch/system/files/2022-01/Sustain%20and%20Retain%20in%202022%20and%20Beyond-
%20The%20global%20nursing%20workforce%20and%20the%20COVID-19%20pandemic.pdf