Written evidence submitted by Royal College of Nursing

1.      Introduction 

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 500,000 members who are registered nurses, midwives, students, and nursing support workers.

1.2   The nursing profession was at the forefront of the response to the pandemic, leading innovation and quality of treatment and care, and demonstrating sophisticated levels of technical skill and competence. The pandemic has shone further light on the highly complex and safety critical standards of practice that the nursing profession works to, and this has been central to the RCN’s campaigns on staffing for safe and effective care, as well as for fair pay, terms and conditions for the nursing workforce. 

1.3   Members of the RCN, like all health and care staff across the UK, are exhausted. Many are experiencing the toll of years of unrelenting pressure through mental and physical ill health and burnout, which were exacerbated during the pandemic. The number one issue facing the health and social care sector in England is the workforce crisis. The UK Government must prioritise the workforce crisis to sustainably and comprehensively address backlogs and waiting times.

1.4   When the Committee published their March 2022 report on NHS backlogs and waiting times in England, the RCN supported the recommendations set out by the Committee, particularly their conclusion on the need for the Government to address longstanding workforce issues and ensure that the health and care workforce is supported to deal with the backlog. The RCN also agreed that the DHSC and NHSE&I need to ensure the NHS workforce is adequately supported and that its service recovery planning is integrated with its planning for staffing. The RCN are concerned that the Government's recent plans and steps taken to address the NHS waiting times and backlog do not take this recommendation into account.

1.5   This submission will seek to address the three main areas identified in the call for evidence:

        The design of national recovery plans;

        Implementation of the recovery plans, including the use of independent sector providers;

        Early progress made in recovering services.


2.      The design of national recovery plans

2.1   In the absence of measures to address the workforce crisis, national recovery plans are not going to meet their intended objectives. Aside from the report by the National Audit Office[i] that the funding allocated to the recovery plans has had its value eroded by inflation, the investment has not been accompanied by a government-funded health and care workforce plan.

2.2   Despite efforts made through national recovery plans, England still has growing waiting lists for treatment on the NHS, with around 7.1 million people needing treatment in 2022[ii]. This is 60% higher than prior to the pandemic and is occurring in the context of an increasing trend in registered nurse vacancies in the NHS in England of around 46,800 in 2022, and falling nursing student admissions.[iii][iv] The latest data shows there will be 2,000 fewer graduating from education in 2025 than there will be in 2024[v]. Unsustainable and often unethical international recruitment is plugging this workforce gap; 48% of new NMC joiners are internationally recruited, with the vast majority appearing to move to England.[vi]


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2.3   Extreme pressures on the nursing workforce are impacting nurse retention – after a decade of real terms NHS pay decrease, sustained staff shortages, low morale and a working environment deprived of investment and resources. The RCN is clear that the UK Government must address the issue of nursing retention as a priority, and that without significant improvements, the crisis facing the NHS will continue.


2.4   Nursing pay in publicly-funded health and care services is the only lever available to the UK Government that would have an immediate impact on retention. Nurses working in the NHS have seen salary levels cut by up 20% in real terms between 2010 and 2022.


2.5   Moreover, UK government proposals for higher education reform, expected to come into effect for the 2023/24 academic year, will disproportionately disadvantage nursing graduates financially. In practice, these proposals represent an even greater pay cut as registered nurses will ultimately be paying back more than higher earning graduates, for a longer period of time. This must be addressed to effectively to tackle the retention crisis in the NHS and deliver recovery plans.

2.6   Government recovery plans to date are solely focused on the NHS and do not reflect an integrated approach across health and social care. A whole systems approach is needed to address hospital waiting lists and delays in accessing health care. The importance of ensuring health and social care services are integrated is vital to service recovery.

2.7   High levels of staff fatigue due to shift work, shift patterns and long working hours can lead to an increase in incidents due to human errors such as lapses in concentration. The consequences of relying on a fatigued workforce to implement the recovery plans are an increased incidence of human error resulting in injury, ill health, staff absence and a reduction in patient safety.

2.8   Continued poor staffing levels across the healthcare sector pose a risk to staff and patients due to unmanageable staff workloads and a lack of adequate rest and welfare breaks.

2.9   In designing recovery plans, implementation of robust and proactive measures to protect staff (including bank and agency staff) who work in different areas of the NHS should be made a priority in order to improve retention of health and care staff in the NHS by ensuring; the provision of adequate training and induction; to include orientation into the area they will be working in; communication of key safety critical risk control measures to staff; and a full risk analysis undertaken by NHSE and NHSI of human factors’ and stress indicators with a specific focus on workload, working environment, training, competence and skills of staff, working patterns, adequate staffing and safety critical communications.


2.10           The RCN’s Nursing Workforce Standards set out what must happen within workplaces in order to deliver safe and effective care, and to improve the decision-making process within nursing workplaces.[vii] These standards must be considered in designing national recovery plans for service delivery across health and care settings.

2.11           Standard 1 makes clear that executive nurses are responsible for setting nursing workforce establishment and staffing levels. All members of the corporate board of any organisation are accountable for the decisions they make and the action they do or do not take to ensure the safety and effectiveness of service provision. Leaders responsible for commissioning plans and services have a duty to ensure that there is a nurse at executive level within an organisation’s governance structure – in order to provide professional, strategic and operational assurance on nurse staffing.

2.12           Standard 2 states that registered nurse and nursing support workers establishments should be set based on service demand and the needs of people using services. This should be reviewed and reported regularly and at least annually and requires corporate board level accountability. Within this standard, the RCN make clear that workforce data should be reviewed at least monthly, and any ‘red flags’ such as high rates of sickness or turnover should be investigated with transparency, in attempt to mitigate impact on the delivery of elective recovery plans.

2.13           Standard 3 states that up-to-date business continuity plans must be in place to enable staffing for safe and effective care during critical incidents or events. Across the health and care service, we are seeing increased demand, waiting times, and record levels of staff vacancies. There has never been a greater need for such continuity plans to be in place, as the current situation poses a significant risk to patient safety – as referenced by the Committee in their ‘Workforce: recruitment, training and retention report’ earlier this year.[viii]

2.14           These standards refer to responsibility and accountability and should each be embedded in the design of all national recovery plans aimed at addressing NHS backlogs and waiting times. In our Workforce Standards, the RCN reference how a lack of nursing leadership and relevant support structures within organisations impacts on safety, quality of care and on the mental health and general wellbeing of the nursing workforce.[ix] Nursing leadership at all levels of the health and care system is critical for improving nursing workforce retention and should be an important factor in the design of all health and care service recovery plans. 

2.15           The RCN is also clear that the UK government should embed a Chief Nursing Officer to hold leadership and provide expert advice within policy-making structures. Each Chief Nursing Officer must be supported by sufficient levels of resource to act.

2.16           Finally, the UK Government must fulfil its commitment to publish an independently verified assessment of future health, social care and public health workforce numbers and skill mix needed in England, based on the current health and care needs of the population and for the following five, ten and twenty years. This must include an assessment of health inequalities across geographies, services and settings, considering where health needs are greatest.


3.      Implementation of the recovery plans, including the use of independent sector providers

3.1   Increasing capacity framework (ICF) with independent providers is a key component of the recovery plans. NHS England has set up a framework agreement with more than 80 independent providers available from April 2021 yet staff representation across the 80 providers is limited to a small number of employers. A sectoral wide forum to establish relationships and encourage dialogue between providers and trade unions is necessary to start to address this.


3.2   Nursing in social care is in crisis, with increased workloads and almost 40% fewer nurses than 10 years ago.[x] Pay for registered nurses employed in social care is also often significantly less than their NHS counterparts, and there is no national pay structure.[xi] Access to training and development for nurses working in social care is limited, as are meaningful opportunities for career progression.

3.3   The CQC reports that recruitment challenges have led to services ceasing to provide nursing care, leading to the relocation of residents to other over-stretched services.[xii] The RCN are concerned about the retention challenges this will be causing, at a time when the nursing profession can’t afford to lose a single professional.

3.4   It must be a priority for the UK government to work with employers across the NHS and the independent sector to improve retention across the nursing profession. The RCN are clear that this focus must include improved pay for nursing staff to address the historic long-term reduction in the value of nursing pay. Regardless of where they work, registered nurses across all health and care settings must have at least parity of pay, terms, and conditions with NHS Agenda for Change. The RCN are calling for a fully funded, substantial and restorative pay rise for NHS Agenda for Change staff at 5% above the rate of inflation (measured by RPI).

3.5   The UK government must also work with independent sector providers to improve working conditions and health and safety across all health and care settings. Employers must also consider the specific context when implementing safety measures for nursing staff, in recognition that nursing staff are more vulnerable in some settings. Staff who are required to work additional hours or through their breaks should be paid at the appropriate overtime rate.


3.6   Independent sector providers must adhere to the ethical code of international recruitment of health and social care personnel in England[xiii], in employing overseas-trained nursing staff to support the implementation of recovery plans. International staff must not be subjected to unfair employment terms and practises and must receive fair pay commensurate with their skills and expertise.


Early progress made in recovering service

4.1   As outlined earlier in this response, NHS waiting lists have continued to rise this year, with 7.1 million people now needing care in 2022[xiv]. This has occurred despite government intervention and system leaders' plans to address the backlog. This suggests that little progress has been made in recovering services and that in fact, the situation is only worsening.[xv]

4.2   The RCN are of the view that until the workforce issues facing the health and care service are addressed – through the delivery of a fully funded government health and care workforce plan progress in recovering services will not be made.

4.3   The RCN are calling on the UK Government to publish independently verifiable assessments of health and care nursing workforce requirements to meet the needs of the population and address health inequalities, for the next five, ten and fifteen years. This should underpin workforce planning, which should be enshrined in law, with government ministers holding accountability for the provision of workforce supply to meet identified needs, based on a transparent assessment of population demand.

4.4   Only by having an accurate and up to date understanding of population demand, will the UK government be able to plan effectively to ensure that the health and care workforce is equipped with the right numbers and skills, in the right places, to tackle the backlog of care and recover health services to efficient and safe levels.


[i] National Audit Office (17 November 2022) Managing NHS backlogs and waiting times in England: https://www.nao.org.uk/reports/managing-nhs-backlogs-and-waiting-times-in-england/

[ii] Institute for Fiscal Studies (15 November 2022) The NHS needs to ramp up treatment volumes if waiting lists are to start falling any time soon: https://ifs.org.uk/articles/nhs-needs-ramp-treatment-volumes-if-waiting-lists-are-start-falling-any-time-soon

[iii] Institute for Fiscal Studies (15 November 2022) The NHS needs to ramp up treatment volumes if waiting lists are to start falling any time soon: https://ifs.org.uk/articles/nhs-needs-ramp-treatment-volumes-if-waiting-lists-are-start-falling-any-time-soon

[iv] NHS Digital (2022) NHS Vacancy Statistics: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey

[v] UCAS (2022) Statistical releases: Daily clearing analysis 2022. A Level Results (15 days after JCQ results day): www.ucas.com/data-and-analysis/undergraduatestatistics-and-reports/statistical-releases-daily-clearing-analysis-2022    

[vi] Nursing and Midwifery Council (2022) Registration Data Reports: www.nmc.org.uk/about-us/reports-and-accounts/registration-statistics

[vii] Royal College of Nursing (2021) Nursing Workforce Standards: https://www.rcn.org.uk/professional-development/publications/rcn-workforce-standards-uk-pub-009681 

[viii] Health and Social Care Committee (2022) Workforce: recruitment, training and retention report: https://publications.parliament.uk/pa/cm5803/cmselect/cmhealth/115/report.html

[ix] Royal College of Nursing (2021) Nursing Workforce Standards: https://www.rcn.org.uk/professional-development/publications/rcn-workforce-standards-uk-pub-009681 

[x] Skills for Care (2022) The State of the Adult Social Care Sector and Workforce in England 2021: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx

[xi] Nursing in Practice (2021), Social Care Nurses to Take a Pay Cut because of NI Rise,

Analysis Finds. (These figures used for the research were based on 2019/20 salaries: a

nurse working in the private care home sector earned an average £31,800 a year and the

RCN estimated the average NHS nurse earned £33,384): www.nursinginpractice.com/community-nursing/social-care-workers-to-take-a-pay-cutbecause-of-ni-rise-analysis-finds   

[xii] Care Quality Commission (2022) The state of health care and adult social care in England 2020/21: www.cqc.org.uk/sites/default/files/20211021_ stateofcare2021_print.pdf

[xiii] Code of practice for the international recruitment of health and social care personnel - GOV.UK (www.gov.uk)

[xiv] Institute for Fiscal Studies (15 November 2022) The NHS needs to ramp up treatment volumes if waiting lists are to start falling any time soon: https://ifs.org.uk/articles/nhs-needs-ramp-treatment-volumes-if-waiting-lists-are-start-falling-any-time-soon

[xv] British Medical Association : NHS backlog data analysis (bma.org.uk), 2022


November 2022