Written evidence submitted by The Royal College of Nursing (ICS0057)

With a membership of close to half a million registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional body and trade union of nursing staff in the world. RCN members work in a variety of hospital and community settings across health and social care. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies, and voluntary organisations.

1. How best can a balance be struck between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for doing so?

1.1. The RCN supports flexibility and autonomy for Integrated Care Systems (ICSs) to meet their statutory requirements by delivering care pathways which meet the needs of their populations. Individual ICSs should set key performance indicators (KPIs) based on evidence of the needs of their population’s demographics and the key risk factors in access and outcomes. This would help to ensure that there is a clear evidence-based need and a quality standard for each ICS to work to.

1.2. ICS’s should have explicit responsibilities to address specific population health needs and key drivers of ill health, including prioritising and reducing health inequalities. For example, this could include a target to reduce cancer diagnoses, which focus on key risk factors for cancer, such as smoking or healthy eating, specific to the evidence of which groups are at risk within the population of that area. The Care Quality Commission (CQC) could then include assessments of each ICS’s progress against these KPIs in its regulation. 

2. How can it be ensured that quality and safety of care are at the heart of Integrated Care Board (ICB) priorities?

2.1. As set out in the RCN’s Nursing Workforce Standards,[i] the nursing workforce is the most important factor in the provision of safe, effective, high quality compassionate care in a timely, cost-effective, and sustainable manner. Nursing has a fundamental role to play in the design, commissioning and delivery of health and care. Nursing leaders drive health policy development and implementation, and lead transformation in both models of care and services. Registered nurse expertise is critical to ensuring decisions are made in the best interests of patients, and robust nursing leadership at board level is vital for ensuring effective and appropriate oversight of quality and safety.

2.2. Ensuring quality and safety is at the heart of the Integrated Care Board (ICB) priorities will necessitate strong nursing leadership within every ICB. The RCN calls for all health and care organisations to have an explicit executive registered nurse leadership role within Board governance structure.[ii] Nursing leadership should be embedded throughout ICS structures, including within executive and decision-making structures across health and care systems, and in every ICB.

2.3. Throughout the parliamentary scrutiny stages of the Health and Care Bill,[iii] the RCN called for nursing to be included in the minimum requirements for the core membership of ICBs. This would have maintained the previous statutory requirement for Clinical Commissioning Groups to have a registered nurse at board level.[iv] UK Government Ministers, however, did not support this call. The RCN is concerned that the absence of this requirement in the Health and Care Act 2022[v] could result in a lack of registered nurse representation at board level and in senior commissioning roles, and that, the overall uneven representation and lack of access to nursing expertise across senior levels of the ICSs would undermine the safety and quality of care.

2.4. Given the unique role, expertise, and insight of nursing across the holistic needs of patients’ populations and other key services, mandated ICB membership for nursing would support strong leadership and management of services. This will ensure that the needs of patients and communities are better met and will highlight the unique expertise nursing brings to patient care in all settings. Furthermore, it is the RCN’s view that, executive registered nurse leaders within health and care Board structures must be given budget-holding status for the provision of their workforce; corporate health and care Board decision-making structures must consider the provision of nursing expertise, record the provision of this and the Boards’ response to the advice given.[vi]

2.5. The evidence and experience of registered nurses shows that having the right numbers of nursing staff, with the right skills, in the right place, at the right time improves health outcomes, the quality of care delivered, and patient safety.[vii] Nursing is a safety critical profession, yet there are long-standing high nursing vacancies across the health and care system in England. This compromises the delivery of safe and effective care and hinders nursing staff from driving forward service improvement and action to address health inequalities, among other pressing challenges. Ensuring a strong and consistent focus on quality and safety of care at ICB level will require a focus on ensuring services are equipped with the right numbers of nursing staff, with the right skills, to deliver safe and effective care that meets population need.

2.6. Each ICB must also take all steps to ensure that its workforce is equipped to provide safe and effective care. To support effective workforce planning and retention across each ICS, there must be a strong focus on the wellbeing and safety of the health and care workforce. The NHS Staff Survey of 2021[viii] shows that in the previous 12 months, 38.3% of nurses have experienced bulling, harassment or abuse from patients, their relatives, or other members of the public. An RCN report[ix] on access to personal protective equipment (PPE) during the pandemic found that over a third of respondents felt pressure to care for individuals with possible or confirmed COVID-19 without adequate PPE, a risk assessment or fit testing for face masks being provided. Additionally, a survey of over 20,000 nurses by the RCN in 2022 [x] found that almost two-thirds (61%) of respondents reported not being able to take the breaks that they were supposed to take. Only 16% of respondents felt fulfilled after their last shift, and more than three times as many (51%), felt demoralised.

2.7. Failing to protect the nursing workforce both physically and emotionally will result in risks to patient care and more staff leaving the profession. For ICBs to maintain quality and safety of care in their locality, providing safe working environments for staff must be prioritised. ICBs must lead the development of a culture that is free from all forms of violence, harassment and bullying and existing legal requirements for the provision of adequate welfare and safety facilities must be properly adhered to prevent burnout and stress.

2.8. The RCN recommends that each ICB has clear explicit accountability for ensuring that services for which they are responsible for overseeing, are providing safe and effective care, which meets the needs of the local population, whilst protecting the wellbeing of the workforce. Ensuring that registered nurse staffing levels are sustainable must be a priority for all ICBs, as inadequate nurse staffing levels compromise the safety and quality of care that patients receive. Executive nurse leaders must be present across every ICB and be able to use their influence to guide and inform nursing priorities for the ICB, including staffing for safe and effective care. The RCN calls for ICBs to adopt the RCN Nursing Workforce Standards[xi] as a tool to set expectations and provide guidance during the commissioning process to ensure that all contracted organisations meet the required standards.

3. How can a focus on prevention within ICSs be ensured and maintained alongside wider pressures, such as workforce challenges and the electives backlog?

3.1. Maintaining a strong focus on the prevention of ill health, health improvement and health promotion within ICSs will be critical for the long-term sustainability of the health and care services, locally, regionally, and nationally. Investing in prevention is cost-effective, can reduce pressure on the wider health and care system, and contribute to wider sustainability, with economic, social, and environmental benefits.[xii]

3.2. The biggest factors driving population health and health inequalities are the conditions in which people grow, work, age and live – otherwise known as the social determinants of health. This includes income, education, employment, access to food, housing, and environment. Therefore, ICSs – through both ICBs and Integrated Care Partnerships (ICPs), should embed health equity as a core principle and priority guiding all decision-making and through the ICPs specially, utilise opportunities to address the social determinants of health through collaboration with a diverse range of system partners. Access to quality equality, diversity and inclusion expertise and training, professional development, and support on health inequalities and prevention is also critical for ensuring that the nursing workforce can deliver with a consistent and effective focus on prevention across all services, contacts, and interventions.

3.3. Nursing has a critical role in protecting and improving the population’s health and preventing avoidable disease. Across all settings, registered nurses and nursing staff play a vital role in health improvement, promotion, and protection, including in primary care and community teams. Many registered nurses work in specialist public health roles across a range of services including school nursing, health visiting, occupational health, sexual and reproductive health, weight management, smoking cessation, and other health protection. Most of these services are commissioned by local authorities, funded via the public health grant, which has been cut by 24% in real terms per capita since 2015/16 (equivalent to a reduction of £1bn), with cuts falling more heavily on those living in the most deprived areas of England who have seen greater reductions in funding even though they tend to have poorer health.[xiii] These cuts have limited local authorities’ capacity to focus on anything beyond the mandated services and to reduce spending on vital services including health protection, smoking cessation, sexual health, children’s public health, obesity and drug and alcohol services.[xiv] Trends in the public health nursing workforce in England since 2015 give serious cause for concern – the number of NHS school nurses has decreased by 26.3%, and NHS health visitors has decreased by 40.3% since 2015. There is an urgent need for investment and action to strengthen these critical services, as part of a stronger focus on prevention and reducing inequalities.

3.4. The RCN has called for the UK Government to invest in strengthening public health and prevention services in England, which will require sufficient increased funding for public health and prevention. This must include a long-term sustainable funding settlement for public health services commissioned and delivered by local authorities to enable them to plan and deliver safe and effective services that improve and protect the health of their population and reduce inequalities. There are significant funding variations across England, and cuts to public health funding have been disproportionately higher in the most deprived areas, where health needs are greatest.[xv] Ensuring that local authorities have sufficient and sustainable public health funding will be critical for ICSs to maintain a strong focus on prevention.

3.5. To support a consistent focus on prevention, the RCN reiterates the importance of having senior registered nurse representation within and across every ICS and ICB to ensure that the unique insights and expertise of nursing into prevention and population health inform commissioning and planning decisions.

3.6. It is also critical that local Directors of Public Health have a consistent and clear role in ICBs and that the ICBs and ICPs’ work is based on a local needs assessment that include the risk factors for specific health needs in each area and address key prevention needs such as smoking cessation, mental health, and wellbeing. The ICS/ICB must also have a clear strategy for scrutiny of care pathway plans, which consider the potential unintended consequences where pathways are amended, or where different providers are bought in. It is essential that KPIs are in place to ensure the health outcomes for the population and or individual patients are maintained and improved by any changes.

3.7. Effective workforce planning is vital to ensure a consistent focus on prevention across ICSs and that there are sufficient staff in the right place at the right time to address population needs now and in the future. Workforce planning must be underpinned by a robust understanding of current population needs and projections for the future. Ensuring fair pay and terms and conditions, equal opportunities for career development and progression, training and professional development across all areas is critical to ensure a sustainable and sufficient workforce that can meet demand, now and in the long-term.

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