Written evidence submitted by Royal College of Nursing


With a membership of almost 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 union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. 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. Summary

1.1   The COVID-19 pandemic has tested the UK Government’s planning and risk assessment capabilities. It is the RCN’s view that insufficient preparation was undertaken by the UK Government for a whole system risk as damaging as COVID-19. The impacts of the pandemic have been unequal across the population, and the Government must incorporate these impacts into future planning and risk assessments.

1.2   The pandemic has highlighted the critical role that nursing plays in protecting, improving, and sustaining people’s health. Nursing staff have been on the frontline of the pandemic, risking their lives to ensure patients were cared for throughout the pandemic including during the first wave when there was a lack of appropriate Personal Protective Equipment (PPE) to protect them.

1.3   The pandemic has also exposed the extent to which successive Governments have underfunded and failed to plan adequately for a sustainable nursing workforce, as part of wider health and care system, and financial planning. The UK Government must take urgent action to invest in measures to develop a sustainable nursing workforce supply that meets the needs of the population now and in the longer term, and to ensure staffing for safe and effective care in all health and care settings.

2         Introduction

2.1   The scale and nature of the COVID-19 pandemic and the UK Government’s response are without precedent in recent history challenging public services, the population and the economy.

2.2   In its recent report, the National Audit Office (NAO) examined the Governments preparedness for the pandemic and found that since 2008, the National Risk Register identified an influenza pandemic as the UK’s top non-malicious risk.[i]

2.3   In addition to this, the Department of Health and Social Care (DHSC) and other Government departments had identified a pandemic as a significant risk to its operations. At a local level, all community risk registers identified an influenza pandemic as a significant risk.[ii]

2.4   The UK Government also undertook Exercise Cygnus in 2016, a simulation of a flu outbreak to test readiness to response . The report found that “the UK’s preparedness and response, in terms of its plans, policies and capability, is currently not sufficient to cope with the extreme demands of a severe pandemic that will have a nationwide impact across all sectors”.[iii]

2.5   It is now clear that the UK Government, like many other governments across the world, was underprepared for a pandemic like COVID-19. It is imperative that lessons are learnt and acted upon to support preparations for and handling of whole-system risks and ensure whole system resilience to future pandemics.

2.6   RCN members, like many of their colleagues across the Health and Care workforce are experiencing the impact of the sustained pressure resulting from the pandemic. In the RCN’s most recent survey conducted in October 2021 with almost 10,000 responses found that nursing staff routinely working unpaid overtime, delayed or did not take annual leave and are feeling exhausted[iv].

2.7   Amid staff shortages, pressure on the workforce continue as efforts are underway to resume routine appointments, elective operations, and urgent cancer care, as well as an treating the increasing number of COVID patients. The scale and expansion of the booster vaccination programme will further increase pressure on staff.[v] Nursing staff need immediate action to prevent irreparable damage to the workforce that will impact them for years to come.

2.8   The impact of the Covid-19 pandemic has been unequal across the population and the UK Government must incorporate this into future planning and risk assessments. Ethnic minorities and deprived communities where health was already poorer have been disproportionately affected, laying bare our population’s poor and unequal health and extensive inequalities.[vi] The longer-term social and economic impacts including unemployment, job insecurity, economic decline, disruption to livelihoods, gaps in educational attainment, increased food insecurity and poverty will exacerbate these.

2.9   COVID-19 has placed significant pressures on the health and care system in England. The RCN recently published a report on 10 Unsustainable pressures on the health and care system in England which highlighted that the varied pressures facing health and care services have been compounded and worsened as a result of issues such as sickness absences and delayed transfers of care.[vii]

2.10                        The Government must acknowledge and plan for the unpredictability of infectious disease management, including learning from the Covid-19 pandemic in order to support preparedness of the health system to protect the population’s health; ensuring capacity and ability for the provision of sufficient resources including equipment such as Personal Protective Equipment (PPE); and rectifying the current absence of a fully funded health and care workforce strategy for England. 





3         Staffing for Safe and Effective Care

3.1   Nursing is the largest safety critical profession in health care. It is vital that there are the right staff, with the right skills, in the right place, at the right time

3.2   The pandemic has highlighted the critical role that nursing plays in protecting, improving, and sustaining health. Working in hospitals, schools, care homes, GPs, prisons, homes and throughout communities with people of all ages, nursing plays a vital role in the provision of safe and effective health and care services as well as addressing the wider determinants of health.

3.3   The pandemic has also exposed the extent to which successive Governments have underfunded and insufficiently planned for the nursing profession across the wider health and care system. Despite soaring demand for health and care services (prior to the pandemic, too few registered nurses were educated and supported to join the profession, with many having left or intending to leave their nursing careers. For colleagues that remain, too many feel overstretched and undervalued.[viii]

3.4   Prior to the onset of the pandemic there were approximately 50,000 nursing vacancies in the NHS across the UK, and an estimated 122,000 vacancies across the social care workforce[ix]. In England, the latest number of registered nursing vacancies is 39,813 in NHS settings.[x] At this time, RCN members were already telling us that many of them were significantly overworked. The 2021 survey found that three quarters of all respondents (74.1%) report regularly working beyond their contracted hours at least once a week; 37.6% do so several times a week and 17.4% report working additional hours on every shift or working day. Of those who reported working additional hours at least once a week, 29.5% report working between one and two hours a week; 37.8% report working between three and six hours; 12% work between seven and 10 hours and a further 12.3% stated they regularly work over 10 hours a week extra[xi].

3.5   International recruitment must always be conducted ethically and complement the growth and development of the domestic workforce. It is important that international recruitment is part of a transparent Government strategy to grow and develop a sustainable healthcare workforce and does not take place at the expense of appropriate education, training and investment in the domestic nursing workforce.

3.6   The failure of the Government to tackle the issues facing the nursing workforce, including in recruitment, retention and burnout, remains a serious risk the country’s ability to robustly tackle the COVID-19 pandemic, as new variants emerge causing cases to rise and further increasing pressure on health and care services.

3.7   Exacerbating the shortages of staff has been the rising sickness absences amongst NHS staff, which has had a direct impact on the sustainability of services. High staff absence rates frequently indicate significant health and wellbeing issues in the workforce, including burnout. Latest NHS staff sickness absence data in England showed that the number of FTE days lost due to sickness have increased by 32% since pre-pandemic, with absence due to mental health reasons being the most common reason.[xii] Staff absences increase the pressure on services and the ability of staff to deliver safe and effective care, as remaining staff are even more stretched as they try to cover for those off sick.

3.8   The workforce crisis was well entrenched in the health and care service before the COVID-19 pandemic struck. The redeployment of staff to the pandemic frontline and the cancelling of routine procedures and preventative services have led to a growing backlog of care that is further making service unsustainable.[xiii] The RCN has serious concerns that nursing capacity is at critical levels and shows no signs of improving in time to deal with the unprecedented backlog of 5.98 million people who are waiting for routine NHS treatment in England.[xiv]

3.9       Currently, in England, there is not yet a shared credible system understanding of workforce shortages and of the increasing demand in both population and service. It is not acceptable for nursing staff to be required to practise in this way or for patient safety to be compromised so severely. Persistent, systemic workforce issues put nursing staff and patients at risk. Without clear legal duties on the Secretary of State for Health and Social Care, the RCN considers the current approach to be a false economy propping up an unsustainable system.

3.10 The RCN is clear that in England the Government must take action to develop a sustainable nursing workforce supply to meet the needs of the population now and in the longer term, and to ensure staffing for safe and effective care in all health and care settings.

3.11    This includes a fully funded health and care workforce strategy, an assessment of workforce requirements in health and social care and accountability for provision of the workforce in legislation. In support of this, the RCN calls for the delivery of an NHS pay award that is fair to attract and retain nursing staff; to enhance pay and conditions in social care, achieving at least pay parity with the NHS, as well as greater investment in the service overall; and to ensure that health and social care capacity is no longer overwhelmed but equipped to deal with the needs of our population.

4         Public Health and Health Inequalities

4.1   Even before the unprecedented public health crisis of COVID-19, England was facing significant public health challenges – including a stalling of improvements in life expectancy,[xv] and people spending more of their lives in poor health.[xvi] 

4.2   There are significant and growing inequalities in health which were clear prior to the pandemic. Those living in the most deprived areas in England are expected to live almost a decade less than those in the least deprived areas.’[xvii] The Prime Minister’s ‘Levelling Up’ speech in July 2021 acknowledged that, “COVID has entrenched problems and deepened inequalities – we need now work double hard to overturn those inequalities”.[xviii]

4.3   Public health services are vital for preventing ill health, improving people’s health, reducing health inequalities and protecting people from health threats.[xix] 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.[xx][xxi]

4.4   The Government’s recently announced review into the impact of potential bias of medical devices recognises that COVID-19 has exposed existing health disparities across the country as the virus had a greater impact on those whose underlying health was poorer and death rates have been higher among people from ethnic minority communities.[xxii]

4.5   There has been increasing Government activity in support of prevention, public health and reducing health inequalities in England, particularly since the pandemic began.[xxiii] This includes ambitions to ‘level up the UK’ and enable people to live an extra five years of healthy life by 2035, while narrowing the gap between the richest and poorest.[xxiv]

4.6   The RCN is concerned that the Government’s stated ambition is yet to be supported by sufficient action or investment in public health, which has been challenged by the Covid-19 pandemic. Public health funding to local authorities was cut by 24% (equivalent to £1bn) on a real term per capita basis compared with 2015/16.[xxv] The effectiveness and sustainability of this vital system has been undermined by chronic underfunding and diminishing resources.

4.7   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.[xxvi] This contradicts the stated aims of the “levelling up agenda and exacerbates health inequalities further.

4.8   Financial pressures and short-term funding settlements announced at a very late stage in the cycle have hindered local authorities’ capacity to plan, commission and deliver public health services.[xxvii] The cuts have limited local authorities’ capacity to focus on anything beyond the mandated services and to reduce spending on vital services including health protection. Some areas of spending have been cut by more than 20% compared with 2016/17.[xxviii]

4.9   This historic underfunding of public health undermined the capacity of local public health teams to effectively improve health and reduce inequalities and respond to the COVID-19 pandemic.[xxix]

4.10    Nursing plays a vital role in all areas of public health, and all nursing roles have public health responsibilities. Many nurses work in specialist public health roles, and hold specialist knowledge in infection prevention and control in a wide range of settings, including schools and care homes. Across all settings, nursing staff play a vital role in health improvement, promotion and protection, including in primary care and community teams. Trends in the public health nursing workforce since 2015 give serious cause for concern – there has been a 26% reduction in NHS school nurses,[xxx] and a 37% reduction in the number of health visitors in England.[xxxi]

4.11 The Government must take action to ensure that there is sufficient resourcing and capacity to support the public health system, including nursing workforce planning. It is also vital that new structures in health and care systems in England have dedicated registered nurse leadership roles, including within Integrated Care Boards, and national bodies, as well as within the UK Government.

5         Personal Protective Equipment (PPE)

5.1   The early stages of the COVID-19 pandemic highlighted the devastating consequences of the lack of Personal Protective Equipment (PPE). These vital resources have been essential for health care professionals, key workers and the population at large, yet the Government did not adequately plan for or have the supply needed for a pandemic of the scale of COVID-19.

5.2   In April[xxxii] and May[xxxiii] of 2020, the RCN undertook surveys to identify RCB members’ experiences with the supply of and access to PPE. The RCN heard directly from members across the country regarding the lack of suitable, sufficient and safe PPE.

5.3   The surveys found that there were ongoing shortages of essential PPE in all settings, and health and care staff were reliant on PPE items being donated or home-made in some cases. In the first survey over a third of respondents reported feeling pressure to care for individuals with possible or confirmed COVID-19 without adequate protection. [xxxiv]

5.4   RCN members reported that this experience was significantly worse for black and ethnic minority nursing staff, where over half (56%) felt pressure to work without the correct PPE. [xxxv] Those working in a care home were most likely to report that they felt pressured to care for individuals with possible or confirmed COVID-19 without adequate protection (41%) rather than those working in a hospital (38%) or the community (24%). [xxxvi]

5.5   The RCN is concerned that the planned removal in March 2022 of central, free PPE provision to the health and care sector[xxxvii] could lead to similar issues with access to PPE and put patients and nursing staff at risk.

5.6   In the early months of the pandemic, national guidance and policy on PPE did not maintain pace with the changing risks and emerging realities of the virus. As a profession, nurses have led the way in reducing transmission by demonstrating excellent infection prevention and control measures. These measures are fundamental to nursing, meaning the profession is uniquely able to understand the importance and methods to reduce infection rates.

5.7   In the current phase of the COVID-19 pandemic, the evolution of variants of concern leading to increasing transmissions and infections must be a national priority. The RCN considers that the UK Infection Prevention Control (IPC) guidance has tended to be slow to be revised. It is important that the most up to date data and knowledge on emerging variants is reflected in the PPE guidance. Employers must be supported to respond quickly and urgently to best protect their staff and patients.

5.8   As such, the RCN continues to advocate for a precautionary approach to the use of PPE, specifically respiratory protective equipment, in order to mitigate the risks of future variants of concern.

5.9   The RCN is clear that all Governments and employers in the UK must ensure that all nursing staff, regardless of practice setting, have access to the necessary PPE of the required standard. With employers juggling the financial challenges faced by the system even prior to the pandemic, as well as new inflation-based higher costs, it is considered by the RCN that maintaining the current free provision of PPE and improving the speed and process of updating the national guidance would ensure safety compliance and minimise the risks of a fast-moving virus. The quality and quantity of PPE that essential health and care workers receive should not be left to chance.

5.10  The RCN also calls on the UK Government to fully involve nursing leaders when designing national guidance on PPE and infection control. Full and proper engagement with the nursing profession on infection control will help to help ensure national guidance is robust, fully informed and evidence based.

6         Recommendations

6.1   RCN members continue to call for the public inquiry into the COVID-19 pandemic to be urgently brought forward so that a full, independent investigation can be undertaken, setting out what will be addressed and beginning this inquiry earlier so that lessons learnt from the Government’s handling of the pandemic can inform our preparedness and response to future health emergencies.

6.2   The RCN is clear that in England, the Government must take action to invest in measures to develop a sustainable nursing workforce supply to meet the needs of the population now and in the longer term, and to ensure staffing for safe and effective care in all health and care settings.

6.3   Persistent, systemic workforce issues put nursing staff and patients at risk. Nursing staff also urgently need a fully funded health and care workforce strategy, an assessment of workforce requirements in health and social care and accountability for the workforce in legislation, set out in clear legal duties for the Secretary of State for Health and Social Care.

6.4   The RCN will continue efforts to strengthen the Health and Care Bill currently making its way through Parliament. [xxxviii] The RCN supports amendments that require the Government to publish an independently verifiable population needs based assessment of upcoming health and social care workforce demand in health and care, and amendments calling for the Secretary of State for Health and Social Care to be made legally accountable for this duty through the Health and Care Bill. There is also a requirement for the Bill to include nursing clinical leadership roles in any legislated health structure, including Integrated Care Boards.

6.5   The system is currently dealing with the immediate challenge of rising COVID-19 cases, winter pressures, and clearing the growing backlog of undelivered care to people in need. Action is needed urgently to retain as many nursing staff as possible in light of serious staffing vacancies, as well as high levels of exhaustion and burnout. This includes on fair pay and better terms and conditions, as well as greater investment in the service overall; and to ensure that health and social care capacity is no longer overwhelmed but equipped to deal with the needs of our population.

6.6   The Government must deliver a long term, increased, sustainable funding settlement for public health services commissioned and delivered by local authorities in England. This will enable local authorities to plan and deliver safe and effective services that improve and protect the health of their population and reduce inequalities. At minimum, the public health grant should be immediately restored to its 2015 level. The most deprived areas of England where health needs are greatest, which have been disproportionately affected by the pandemic, should receive additional public health investment to level up health across the country and support an equitable recovery from the pandemic.

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[i]  The government’s preparedness for the COVID-19 pandemic: lessons for government on risk management - National Audit Office (NAO) Report

[ii] ibid


[iv] Royal College of Nursing (2021) Employment Survey

[v] Royal College of Nursing responds to Prime Minister's COVID-19 booster programme statement | Royal College of Nursing (

[vi] NHS England » Action required to tackle health inequalities in latest phase of COVID-19 response and recovery

[vii] Royal College of Nursing (2021) 10 Unsustainable Pressures on the Health and Care System in England | Publications | Royal College of Nursing (

[viii] RCN (2020) Gender and Nursing as a Profession: Valuing nurses and paying them their worth

[ix] Skills for Care, The state of the adult social care sector and workforce in England,

2019 (Leeds, 2019). Available at

[x] NHS Vacancy Statistics England April 2015 – September 2021 Experimental Statistics - NHS Digital


[xii] NHS Digital (July 2019 and July 2021) sickness absence rates

[xiii] Royal College of Nursing (2021) 10 Unsustainable Pressures on the Health and Care System in England | Publications | Royal College of Nursing (

[xiv] NHS England (2021) consultant-led referral to treatment waiting times – October 2021

[xv] Kings Fund (2021) What is happening to life expectancy in England? | The King's Fund (

[xvi]Michael Marmot, Jessica Allen, Tammy Boyce, Peter Goldblatt, Joana Morrison (2020) Health Equity in England: The Marmot Review ten years on. London: Institute of Health Equity

[xvii] [accessed 12 August 2021]

[xviii] Prime Minister's Office, 10 Downing Street and The Rt Hon Boris Johnson MP (2021) The Prime Minister's Levelling Up speech: 15 July 2021

[xix] Kings Fund (2021) Spending on Public Health

[xx] WHO regional Office for Europe (2014) THE CASE FOR INVESTING IN PUBLIC HEALTH

[xxi] Martin S, Lomas J, Claxton K from the University of York. Is an ounce of prevention worth a pound of cure? Estimates of the impact of English public health grant on mortality and morbidity. CHE Research Paper 166. July 2019.

[xxii] Review launched into the health impact of potential bias in medical devices - GOV.UK (

[xxiii] DHSC and Cabinet Office (2019) Advancing our Health: Prevention in the 2020s

[xxiv] Conservative Party Manifesto (2019)

[xxv] The Health Foundation (2021) ‘Public health grant allocations represent a 24% (£1bn) real terms cut compared to 2015/16’ Health Foundation response to announcement of the public health grant allocations for 2021–22

[xxvi] Local Government Association Health and local public health cuts briefing House of Commons 14 May 2019

[xxvii] Kings Fund (2019) Public health spending: where prevention rhetoric meets reality

[xxviii] Kings Fund (2021) Spending on public health

[xxix] Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Herd, Joana Morrison (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity

[xxx] NHS Digital (2021) NHS Workforce Statistics – August 2021S Workforce Statistics - March






[xxxvi] ibid

[xxxvii] DHSC (2021) Extending free PPE to the health and care sector - GOV.UK (

[xxxviii] Health and Care Bill - Parliamentary Bills - UK Parliament


January 2022