Written evidence submitted by The Royal College of Nursing (RTR0092)

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 465,000 members who are registered nurses, midwives, students, and nursing support workers.
 

1.2   The nursing profession has been at the forefront of the response to the ongoing 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 have been exacerbated during the pandemic.
 

1.4   RCN members have made it clear that unless changes are made to nursing staff pay and working conditions, there is significant risk of rising numbers of nursing staff leaving the profession[i].
 

1.5   In order to educate enough registered nurses and improve retention within the existing nursing workforce, to deliver the safe and effective care that is needed now and for the future, the UK Government must be made legally accountable for workforce planning and supply, by amending the Health and Care Bill currently working through Parliamentary process.
 

2. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?
    

2.1   There are currently 39,813 (10.5% vacancy rate) vacancies in the registered nursing workforce in the NHS in England.[ii] The current UK Government carried through a Conservative Party manifesto commitment to recruit 50,000 more NHS nurses for England by 2024. [iii] However, the forecasting or modelling underpinning this goal is not publicly available, and there is not yet a published plan for achieving this target – despite the UK Government acknowledging the Health and Care Committee’s recommendation that the Department of Health and Social Care produce a set of costed and detailed action plans for each of the different supply routes for nursing, including how many nurses each route is expected to contribute to the nursing workforce, by Autumn 2021[iv]. There is, therefore, no public assurance the 50,000 target reflects actual requirements, now or in the longer term. Furthermore, this target is understood to be for the NHS alone, and if so, does not appear to holistically recognise the workforce needs of the health and social care system, including an assumption that all entrants into the nursing profession would choose NHS roles.
 

2.2   Available estimates suggest that the 50,000 more nurses committed to by the UK Government in England will be insufficient to meet the increased demand on the nursing workforce. Many stakeholders, including the RCN, argue that robust, independent projections of the future demand for and potential supply of registered nurses must be part of a shift to a sustainable, long-term approach to nursing workforce planning.[v] 
 

2.3   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 for patient care. However, these alternative routes – such as the nursing degree apprenticeship - are not sufficient to solve workforce issues. The traditional three-year university route alone 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. [vi]
 

2.4   A summer 2021 survey of RCN student members undertaking undergraduate and postgraduate nursing degrees found that over 90% of respondents said their finances as nursing students caused them some level of concern. More than a quarter reported considering dropping out of their course due to these concerns[vii]. Of those who expressed financial concerns, 90% said that this impacted their mental health[viii]. Respondents described that the experiences and pressures on the existing nursing workforce during the pandemic also affected nursing students, who described being routinely expected to perform duties outside the usual remit of their roles whilst on practice placements, which could cause even more nursing students to consider leaving their courses. There is a risk that this context could continue to deter potential nurses, unless conditions for all nursing staff and students improve[ix].
 

2.5   In 2017, the UK Government replaced the nursing bursary in England with a loan-based system[x], leading to an immediate significant decline (51,840 in 2016 to 40,060 in 2017) in the number of people applying to study nursing in England[xi]. The introduction of a £5,000 maintenance grant (up to £8,000 in limited circumstances) in January 2020 coincides with an increase in the number of applicants and acceptances between 2019 and 2020 of 18% (5,800 more applicants) and 27% (5,215 more accepted applicants) respectively[xii]. This suggests the introduction of the grant is part of a necessary and effective measure to support new recruits.

2.6   The RCN is clear that recruits to nursing higher education in England must increase significantly, and 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 students[xiii]. 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 stress[xiv].
 

2.7   In the medium and long-term, domestic supply of the nursing workforce must grow to keep pace with population and workforce demand. It is the RCN’s view that to enable sufficient and sustainable recruitment of nursing staff across health and social care now and in the long-term, including retaining those who might be considering leaving and attracting leavers to return, pay and working conditions for the nursing workforce must be improved.
 

2.8   The RCN is asking for 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.
 

2.9   The RCN is calling on the UK Government – currently through amendments to the Health and Care Bill - to make the Secretary of State for Health and Social Care legally accountable for health and care workforce assessment and planning, to ensure all actions for workforce supply are set out in a published plan that is 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.
 

3. What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?
    

3.1   The RCN is clear that the UK Government’s plans for the recruitment, retention and training of registered nurses and nursing staff must move to a more sustainable demand-led workforce planning model based on long-term population projections and changing population needs, to ensure that the nursing workforce numbers and skills are able to adequately meet the care needs of the population, as set out in the response to Q5.
 

3.2   Fair pay for nursing staff is a policy lever immediately available to the UK Government to improve retention and recruitment of nursing staff and the UK Government must take immediate action to ensure fair pay for nursing staff working across health and social care.
 

4. What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?
    

4.1   International recruitment must be part of a transparent UK Government strategy to grow and develop a sustainable healthcare workforce, in addition to the valuable external learning that overseas colleagues bring. However, international recruitment should not take place at the expense of appropriate education, development and investment in the domestic nursing workforce.
 

4.2   The RCN is concerned that given existing workforce gaps in both health and care, social care remains particularly vulnerable, and should be better supported to further draw upon international workforce in the short-term. As in health, demand for social care will also continue to grow - by 2035 the care sector may require an extra 490,000 jobs in England alone, equivalent to 29% growth.23 All current barriers should be removed so that international care workers have a clear route to employment in the UK. The UK Government’s recent decision to include care worker roles on the Shortage of Occupation List[xv] can only be effective if the salary threshold for these roles is removed.
 

4.3   International recruitment must always be conducted ethically, and follow the principles set out the in the UK Code of Practice[xvi] and the World Health Organization (WHO) Global Code of Practice[xvii]. The RCN is concerned by the number of nurses joining the NMC register from countries identified by the WHO as facing pressing health workforce shortages, where active recruitment is not supposed to be permitted. As a matter of urgency, the UK Government must seek to introduce mutually beneficial Memorandums of Understanding to govern ethical recruitment with any countries where there is evidence this is occurring.
 

5. What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?
    

5.1   Barriers within the UK Government’s immigration rules should be addressed to ensure that the UK remains an attractive destination for international nurses, and also to make it easier for international nurses to be able to work in the UK. For example, RCN members report difficulties in bringing family members to the UK through the Sole Responsibility and Adult Dependency routes, because of the high burden of evidence that is required by the Home Office – this can potentially leave nurses separated from direct family members that might require their ongoing care.[xviii] Ultimately, these kind of barriers within the immigration system can present real challenges to internationally educated nurses, and can also contribute to ongoing recruitment and retention challenges for the workforce within the UK.   
 

6. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:
    
7. To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?
    

7.1   It is the RCN’s position that there should be publicly available and transparent UK Government system and 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 – including for specific initiatives such as the costing and detail of plans to recruit 50,000 more nurses.
 

7.2   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.
 

7.3   Publicly available 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. [xix] Such projections should be observed and used by the UK Government to inform workforce planning, as part of UK Government accountability for workforce assessment and planning - as the RCN recommend should be held by the Secretary of State for Health and Care as part of a legal duty, as set out in the response to Q1.
 

8. Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?
    

8.1   The Nursing and Midwifery Council (NMC) updated the Standards for Nurse and Midwifery Education in 2018, and university curriculums for pre-registration nursing students changed to meet these, including developments in digital health, prescribing and public health.[xx]
 

8.2   Further patient involvement in nurse education through placements in a wider range of settings and simulation activities have increased the number and variety of skills nursing students develop, and their awareness and communication skills – both vital for providing safe patient care.
 

8.3   Toolkits developed in response to changes to the NMC standards, such as the genomics toolkit,[xxi] are enabling registered nurses to respond to new innovations in healthcare, supporting nurses to increase their knowledge of new technologies which will enable them to contribute to improved patient care.
 

8.4   Ongoing higher education during a nursing career enables registered nurses to develop their careers, become specialists in both acute and long-term conditions such as cancer, respiratory, cardiac, and a variety of others, as well as design, lead and deliver innovative care models to meet changing population needs. Career development is critical to keeping professionals supported within the workforce, essential for ongoing safe and effective practice, and for career progression; all of which contribute to both recruitment and retention.
 

8.5   The UK Government announcement in the 2021 Budget represented only a £30m increase over 2015/16 levels, despite years of under-investment in professional education and inflation[xxii]. This funding was not provided to all NHS-funded nursing staff, nor did it include staff in publicly funded social care and public health services[xxiii].

8.6   The UK Government must go further and develop a strategic approach to levels of CPD requirement, based on modelling of future service and population-based need, as well as correctly identified skill mix and establishment[xxiv]. It is the RCN’s position that this should be ring-fenced for all nursing staff in all settings and sectors, as a critical aspect alongside pay progression and career development opportunities[xxv].

8.7   However, investment in higher nursing education is not aligned with the ambitions of the health and care service in England. The 2015 HM Treasury Spending Review cut 60% of the Health Education England (HEE) budget for Continuing Professional Development (CPD) for NHS nurses (from £205 million in 2015/16 to £83.49 million in 2017/18)[xxvi]. In contrast, the ‘future workforce’ postgraduate medical and dental budget was increased by 2.7% in 2017/18[xxvii]. This significant disparity between the nursing and medical professions must be reconciled[xxviii] [xxix].
 

9. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?
    

9.5   The RCN has identified several factors driving registered nurses to leave the health and social care sectors. The 2021 RCN employment survey[xxx] - registered nurses, health care support workers, students and nursing associates working across all areas of health and social care – found almost six in ten respondents (56.8%) are considering or planning leaving their current post. Intention to leave was strongest among nursing staff working in NHS hospital settings, and the main reasons given for thinking about leaving were feeling undervalued and experiencing too much pressure.
 

9.6   An RCN 2020 survey[xxxi] found that around a third (35%) of respondents in England said they would be considering leaving the profession by the end of the 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 conditions[xxxii].
 

9.7   The RCN 2021 employment survey 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 provide[xxxiii].
 

9.8   On satisfaction with pay, around six in ten (62.7%) reported their pay band or level as inappropriate.[xxxiv] The main reasons for dissatisfaction are that pay levels have failed to keep up with increases in the cost of living, a perceived failure to reward nursing staff fully for their effort and contribution, and dissatisfaction with organisational pay structures[xxxv].
 

9.9   For too many nursing professionals, their salaries have not kept pace with the continued increases to their living costs over the past decade, or been enough for them to feel fully rewarded for their work - the impact of this on retention should not be underestimated. Registered nurses and nursing staff 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 decade[xxxvi].
 

9.10  The RCN is concerned that increased demand on the health and care system throughout the pandemic, in the context of prior existing high vacancies and unsafe working conditions has meant registered nurses and nursing staff are continuing to shoulder a large and unsustainable workload.
 

9.11  The most recent published NMC register data shows that the number of leavers has increased compared to the same period in previous years.[xxxvii]
 

10     Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?
 

10.1  No issues with particular areas of practice or geography can be effectively addressed without addressing the overall issue with the pipeline of supply when it comes to the registered nurse workforce. The NMC leavers data is broken down by registration type, and also by UK/EU/non-EU registrants. The most recent NMC data shows the number of nurses leaving the UK register increased by 11.3% from 2020 to 2021 - with a total of 2,372 leavers. Whilst NMC data shows the field of practice nurses are registered in (Adult, Children, Learning Disabilities, Mental Health), it does not show the specific areas of practice nurses are working in, for example, roles in the community.
 

10.2  NMC joiners and leavers’ data could be broken down further to show figures for more specific geographical locations – for example by region, to helpfully determine whether recruitment and retention are particular problems in specific geographical locations – data which is not currently publicly available.
 

10.3  Recruitment and retention are a particular problem for the nursing workforce in social care. In 2021, registered nurses working in social care had the highest turnover rates of any job role in social care – at 38.2% - which is much higher than counterparts working in the NHS, who had a turnover rate of 8.8% as at March 2021[xxxviii]. The number of registered nurses working in social care continued to decrease year-on-year between 2012/13 and 2019/20, and in 2021 was down 1,800 jobs (5%) on the previous year[xxxix]. Registered nurses were one of the only jobs in adult social care to see a significant decrease over this period (down almost 17,000 jobs, or 33% since 2012/13)[xl].
 

10.4  To address recruitment and retention issues in social care, the sector needs increased long-term investment. Funding for the social care sector must be sufficient to provide fair pay, terms and conditions for all nursing staff, to encourage recruitment and retention, and must be included in Government accountability for assessment and planning of the health and care workforce.
 

11     What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

11.1  The latest iteration of the NHS People Plan pledged to grow the NHS workforce, however, it did not provide costs or a plan for how this would be delivered, and only outlined proposals for 2020/21[xli].The RCN is clear that in order to fully address the recruitment, training and retention issues across the health and care service, the Secretary of State for Health and Social Care must hold legal, central accountability for workforce assessment, planning and supply, as set out in the response to Q1.

11.2  Whilst the People Plan’s commitments to support retention of the nursing workforce are helpful, the next iteration must set out action in the short and long term to understand the health and care workforce shortage and address the significant issues in recruitment of domestically educated nursing staff.

11.3  The next iteration of the NHS People Plan, and a people plan for the social care sector must prioritise the need for the UK Government to hold accountability for assessing the health and care workforce and delivering a strategy for workforce planning and supply.

12     To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?
 

12.1  In the NHS, through Agenda for Change there is a nationally recognised system of pay and conditions. As well as national pay scales there is a job evaluation scheme that provides a system to measure job value, which seeks to ensure equal pay for work of equal value across job roles within NHS employers. Having a national system can be an effective model and mechanism for supporting recruitment and retention across the NHS. However, the implementation of the system must be effective and equitable across all NHS employers.
 

12.2  A current failing in the system, however, is that the job descriptions utilised for nursing roles are frequently out of step with the reality of the skills, knowledge and accountability of the safety critical roles that nursing staff deliver. In addition, there is no national system for verifying the consistency of the outcomes of the job evaluation process for nursing roles between different NHS employers. The national nursing profiles have not been reviewed in years, and the number of nursing roles at different pay bands within NHS services appears to be driven more by budget constraints rather than full recognition of the skills and responsibilities involved in the role. The RCN has called for an urgent review of the Job Evaluation outcomes for nursing roles, as without this the current system is in danger of failing to deliver the workforce required for safe and effective care[xlii].
 

12.3  More than half of social care is funded by the public purse and with the funding pressures on commissioners, which results in significant cost pressures on employers. The nursing workforce is then viewed as a cost burden rather than a workforce to be invested in to promote the effective reward and recognition for the skills and accountability of nursing as a safety critical profession.
 

12.4  A lack of collective bargaining means that the employment terms and conditions across social care are variable decisions made by employers, on terms and conditions including pay, unsocial hours payments, pension, maternity pay, annual leave and occupational sick pay. This fails to deliver contractual and employment conditions fit for attracting and retaining the right numbers of nurses and nursing support workers within the sector. Contractual agreements, rates of pay, and terms and conditions vary widely between employers, are sometimes variable within the same employer, and are rarely transparent. It is the RCN’s position that regardless of where a registered nurse or nursing staff member is employed, they should at least have parity with Agenda for Change pay, terms and conditions.
 

12.5  Within social care, there are a considerable number of employers. Funding and staff turnover are significant challenges, accentuated by a lack of opportunity for career progression in the sector. Pay is often set just above legal minimum wage levels, terms and conditions of employment are poor, and training and CPD opportunities may also be limited or non-existent.
 

12.6  The RCN has received reports from some international members working in the care sector in the UK, that they are working within contracts that contain what could be considered excessive early exit fees[xliii]. Such early exit fees present a clear risk that there are circumstances in which some workers may feel pressured to remain within contracts when they would otherwise choose to leave.