Written evidence submitted by The Nuffield Trust (RTR0114)

The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. We have consistently noted that insufficient and inconsistent staffing rules out achieving a strong, improving health and social care sector. The Committee’s inquiry is an important opportunity to focus on solutions. This submission addresses the Terms of Reference across four areas: domestic training and recruitment, recruitment from overseas, the areas in greatest need, and how to retain and attract staff

Key points

• Attracting NHS staff from overseas is necessary in the medium term. The Government needs to consider how cost, the speed of the process, and perceived discrimination affect the decision to join England’s health service.
• Staff drop out of training at a rate higher than we should accept, with a loss of 40% of nursing students and almost half of GP trainees. There should be conditions on providers of clinical education, which take into account dropout rates.
• Removing bottlenecks for training professional staff, especially nurses, is likely to require more funding for both universities and trusts providing placements. There is a case for shifting money towards nursing from the more generous funding for trainee doctors.
• Staff groups in particular need of greater focus include domiciliary social care workers, senior social care managers, doctors with generalist skills, and rehabilitation specialists.
• Low pay and poor working conditions in social care are damaging recruitment and retention. While widely recognised these issues are not being addressed, even as countries like France and Germany increase wages sharply to find the staff they need.
• While evidence shows that receiving training and recognition for skills encourages people to stay in social care, higher training requirements for certification may not help if pay and conditions continue to create a negative perception. Better trained but poorly paid and undervalued staff may use their skills to get jobs outside social care.
• A perception of social care staff as undervalued and neglected may have been unfortunately reinforced by some developments during the pandemic.
• Most other countries with points-based systems have found a need for special routes for people migrating to work in social care. It remains to be seen whether the costs, bureaucratic burden on often small businesses, and salary threshold will be overcome to make the recent new allowances for social care migration work in England.

Introduction

The Committee is right to take as a given that there are multiple serious problems with the numbers of care staff in England. In the NHS, chronic shortages of nurses have persisted for over a decade and will be a deciding constraint in stopping services from expanding to meet needs after the pandemic. Repeated failures to meaningfully increase the number of doctors in general practice have left the sector dangerously overstretched even as plans and policies rely on in taking on more responsibilities.[1]

In 2019 we estimated that an additional 50,000 social care workers were needed just to provide one hour of care per day to older people with high needs currently getting no help.[2] Our latest analysis has in fact shown a sharp fall of 42,000 in the number of staff in the 6 months to the end of October 2021. The true figure is likely 50-70,000.[3] The national average vacancy rate has climbed to over 9% in November 2021.[4] We are concerned that social care is at risk of system failure.

This submission sets out what we see as the key policy options to address these deeply rooted issues.

1. Domestic training and recruitment

1.1. University and clinical placements

Overseas recruitment is vital in the short term, but there is rightly a longer term ambition for a sustainable, homegrown NHS workforce. While the numbers joining medical school have increased[5], the number of students starting nurse training plateaued last year.[6]

One barrier may be a lack of incentive for universities to provide more places and courses. The Office for Students provides funding to universities where course costs cannot be met through fees alone. This attempts to account for the clinical equipment, supervisors, and experiences required. However, to incentivise more places for the right courses in the right places, we support the independent review of post-18 education recommendation that the Office for Students reviews funding rates, giving consideration to support for socially desirable professions such as nursing.[7]

A lack of clinical placements is sometimes a bottleneck. Pressure on services makes it harder to offer these. HEE currently funds providers to cover the direct costs of training, including staff teaching time, during clinical placements. However, there is a lack of transparency on where some of this funding goes, particularly for medical placements.[8]

There are huge differences in funding levels between staff groups which may distort the provision of places. Providers receive around 10 times more for some medical placements each year (up to £44,000) than for nurse placements (up to £4,000).[9] In addition, for junior doctors only, HEE funds half of basic salary costs. This may incentivise this staff group to be overused and undervalued.[10]

We previously recommended national bodies reset the level and balance of funding for clinical placements and salary support for clinicians in education and training. We noted this could potentially involve a shift of funding from medical to nursing and other non-medical training.[11]

1.3. Attrition in the journey to professional roles

A quarter of UK students who began a three-year degree due to finish in 2017 left or suspended their studies. One estimate suggesting that out of every 100 adult nurse training places commissioned, only 58 full-time equivalent (FTE) staff enter the NHS.[12] Our own exploratory analysis found a similar ratio, shown in Figure 1.[13]

Figure 1. Undergraduate nurse training pipeline

The Royal College of Physicians recently estimated a 'loss' of one in four people from medical school to an appointment as a consultant[14], although it should be noted that not all doctors want this career path. Our own analysis suggested perhaps one full-time equivalent GP joins the NHS for every two starting specialist training.

These levels of attrition are not inevitable. We have recommended that commissioners of medical, nursing and allied health professional courses and placements set conditions on the quality, success and balance of the training, taking into account variation between institutions.[15] This must be informed by accurate monitoring of attrition.

1.3. Apprenticeships in the NHS

Apprenticeships have the potential to support wider participation: they are popular with older entrants, attract people from diverse backgrounds[16], and present an opportunity to recruit more locally.

To date, though, the model has been delayed and numbers are low; around 4,200 had started nursing degree apprenticeships in the three years to July 2021. Apprenticeships for nursing associates (a bridge between healthcare support workers and registered nurses) were also introduced, with an aim to recruit 5,000 new trainee nursing associates in 2018, and 7,500 more by March 2020. Both targets were missed.[17]

Previously, some more intensive apprenticeship routes appeared financially unviable for providers, potentially costing a Trust around £140,000 over and above the levy.[18] While new funding was announced to support nurse apprenticeships in August 2020, it will be important to monitor how this affects the numbers being provided. In addition, there may also be scope– in line with proposals by NHS Employers and the Education Select Committee – to increase the maximum funding level and flexibility in how it is used, and to improve regional co-ordination including between health and social care settings.[19]

1.4. Social care

Only an estimated 5% of social care workforce in England are regulated professionals. The general attractiveness of the sector as a place to work, as opposed to the availability of qualified staff, is the key limit on recruitment.[20]

Yet despite social care being recognised as a low pay sector for over 20 years, there are no further ambitions to improve pay within this parliament, a notable absence in the government’s social care white paper.[21] The temporary Infection Control Fund and emergency payments by local authorities have been relied on to recruit additional staff, but sporadic injections of money are no substitute for a long term settlement that allows better pay and conditions to be offered with certainty.

Further central government funding to help providers recruit and retain staff (£300m in December 2021 and £162.5m in October 2021) is welcome but falls markedly short compared to the bolder action taken by other countries. Scotland has benchmarked care worker pay to NHS Agenda for Change band 2; France increased pay by 13-15% per hour for domiciliary care staff; and Germany is increasing the sector wage to well above the national minimum (11-16% by April 2022).

The issues described below in pay, training and conditions for existing staff likely have an impact on recruitment as well as retention. Our NIHR-funded research on the impact of Covid-19 on social care pointed to instances of staff not being formally recognised as key workers and poor access to testing and PPE. We are concerned that these inadequacies cemented perceptions of social care as a neglected, undervalued sector.

2. Overseas recruitment

1.1. National Health Service and registered professionals

In the short and medium term, attracting staff from overseas is vital to addressing staffing shortages and meeting workforce goals.[22] The potential numbers are large. Some 49,000 nurses were recruited to the UK in a four-year period in the early 2000s.[23]

Perceptions around quality of life, working conditions, and opportunities can all be important factors in the decision to migrate. Professional motivations appear more common from migrants from higher income countries: pensions, pay and public services are more common for those from poorer countries. Our work suggests barriers and incentives including:

-          Perceived levels of discrimination and of visa restrictions to reunite with family which damage the desirability of England as a destination.

-          The length of the recruitment process, a key factor for many in choosing countries. In 2019, the NMC launched a streamlined overseas registration process for nurses. It will be important to monitor whether this makes a substantial difference.

-          Given the importance of feedback loops to source countries, we need to better understand and address any issues faced by overseas staff. Employers and national bodies all have a responsibility here to collate and survey experiences of these staff. [24]

The organisations recruiting may also need help given the initial costs and administrative burden involved. The upfront costs in recruiting from a nurse from overseas is likely to be around £10,000 to £12,000. That said, this equates to only around £1,000 per year – or 3% of the mean annual nurse salary – if considered over the typical average NHS career of a nurse from outside the EU.[25] Previous financial support from NHS England & NHS Improvement appears to have helped overcome some of these barriers. There needs to be a mechanism to provide help to general practice and social care.

The Code of Practice for the international recruitment of health care personnel aims to avoid active recruitment from lower income countries with pressing health workforce challenges. Data show there has been, at times, significant passive recruitment from countries on the no-active-recruitment list. In the spirit of inclusion and recognising individuals may be escaping difficult situations, we believe some level of passive recruitment may be acceptable. However, compensation for the loss of clinical assets should be considered.[26]

2.2. Social care workers

The example of other OECD countries with points-based immigration systems such as Australia, New Zealand and Canada suggests international recruitment will continue to be a necessary part of England’s social care workforce strategy.[27]

In the short term, the introduction of care workers to the Shortage Occupation List and health and care visa will allow employers to sponsor care workers on a minimum salary of £20,480 per year. However in the independent sector the mean annual salary remains at £17,900 per year and small and medium employers face steep recruitment costs.

In the longer term, the UK could learn lessons from other countries’ attempts to wean themselves off international recruitment, such as in New Zealand where the government has introduced a sector settlement agreed with care providers.

Migration under the skilled visa system requires many administrative steps and fees which may total several thousand pounds across the worker and their family. Many small social care providers will find this difficult compared to NHS trusts. Integrated care systems have a role to play supporting smaller providers with fees.[28] 

3. Areas of most need

3.1. Staff groups facing particular shortfalls in social care

Our research suggests recruitment challenges are shared by providers across all settings – rural and urban, private and public.

However registered nurses and domiciliary care workers face especially severe shortages.[29] We heard from one homecare provider that in one round of recruitment of 100 people, 10 were eventually recruited and only 2 of these could drive. Long waiting times for drivers’ tests (6 months) are worsening the situation, particularly in rural areas. [30]

Our research interviews suggested that many senior and experienced registered managers have remained in post out of a sense of professional duty but intend to leave once the pandemic has passed. As such, staffing levels for more senior and experienced staff are a particular concern.

3.3. Doctors with generalist skills and rehabilitation

Patients arriving as emergencies increasingly have multiple conditions and take many medications. They may have complex social or mental health issues as well. This makes acute medicine, geriatric medicine and other general medical skills increasingly important.

Unfortunately, medicine has become more specialised. Many physicians who use to deliver emergency care to these patients have opted out in favour of more specialist work.  The burden on the remaining physicians and in particular on the middle grade doctors makes recruitment into these roles more difficult.[31] The design of many emergency services and the lack of continuity for many admitted patients may also be contributing to burnout and retention problems.

Steps have been taken to strengthen the general medical training of trainees in medical sub-specialties, but more needs to be done and the NHS will also require more trainees and consultants with entirely generalist roles.  Expanded training of generalist doctors should create the opportunity to allocate training places more evenly, and to allocate senior trainees to smaller hospitals who often need them most. The health service needs to consider making registrar roles in acute medicine more attractive.

Rehabilitation is also an area of major underinvestment, with the provision of rehabilitation medicine between different parts of the country.  The shortage of rehabilitation services is one of the contributing factors in difficulties in discharging patients.  There is a need to expand the number of specialists in this area and also in some of the allied health profession roles that support them.

3.3. Addressing regional disparities in NHS training

Many clinical students take up work near where they trained. A quarter (24 per cent) of all licensed doctors who qualified in England live within 10 miles of the medical school where they qualified.[32] The responsibilities determining the location of training are mixed, with the Office for Students determining the distribution of medical school places, while HEE determines clinical placements. We have recommended that the commissioning of clinical placements should be done in a way that exposes students to a wider range of locations.[33]

As it is now largely left to the market, there is limited central control over the distribution of most nursing and allied health care training posts. National, regional and local health bodies must take the initiative to work closely with universities to ensure the supply of staff meets the needs of all areas of the country.

The current distribution of courses does not appear to be optimal. For example, our work on mental health nursing found that, in 2018, there were some three times as many acceptances per 100,000 in the North East of England as the South East, with the latter already struggling with staffing shortages. There were no opportunities to study mental health nursing in parts of the South and East of England (Figure 2).[34]

Figure 2. Distribution of mental health nurse training courses in England

4. Retention, contracts, and conditions

4.1. Contractual and employment models in social care

The contractual and employment models used in social care are widely considered not fit for purpose. Our NIHR-funded research has highlighted the importance of occupational sick pay for a sector in which 24% of workers are on zero hours contracts[35] and eligible only for statutory sick pay. Flexible hours are valued by some workers but there remains concern that the use of zero-hours contracts facilitates precarious employment, with consequences for staff wellbeing and quality of care.

The time and task model (i.e. 15-minute homecare visits) dominates much of social care commissioning with impacts on the type and quality of care which can be delivered. No amount of staff training can make up for this; in order to deliver high quality care, the wider conditions of work must change too. Such action is possible with political will - in May 2020, prompted by the covid-19 pandemic, the Swedish government agreed with labour unions and municipalities to invest 2.2 billion Swedish kronor in training and fund 10,000 new permanent assistants to plug shortages.[36]

4.2. Training and retention in social care

There is a link between continued investment in training and retention in social care – care workers who receive training are 9% less likely to leave than those who receive none at all.[37]  Several changes have recently been proposed to initial and ongoing training. However, investing only in training without improvements in pay or working conditions may have limited or even perverse results.

Commitments on training in the government’s white paper are promising. These include the introduction of a knowledge and skills framework, making the care certificate more portable, and a voluntary, digital central care workforce hub which may establish “a foundation for registration of staff in the future”.[38] The Health and Social Care Levy pledged £500m towards workforce development and wellbeing support, and £200m towards training assessors.

Our research suggests statutory registration and regulation is seen by many as a first step towards professionalisation of unregulated care workers.[39],[40],[41] In the other UK nations, registration and regulation of the workforce are tied to ongoing mandatory training and qualifications, providing a means to drive up the standards and professional development of the workforce. The DWP In-Work Progression Commission recommended that a central body be established in England for care workers, to manage and certify training, help set out a clear progression pathway for low-paid workers, and transform perceptions of care as a profession.[42]

But professionalization and registration should not be seen as ends in themselves, and evidence on the impact of changes elsewhere in the UK is limited. DHSC should commission an independent evaluation of statutory registration of care workers. Learning from Japan suggests that while setting higher training requirements may help to enhance the status of care work, unless it is matched with improved working conditions and improved pay, it risks exacerbating workforce shortages.[43] Our own research within England showed better training without better pay can backfire as more highly skilled staff look for opportunities to leave social care for the NHS.[44]

4.3. Pay in social care

There is clear evidence that competitive wages for each local labour market and improving employment conditions would reduce staff turnover, [45],[46] which stands at 29.5%[47]. While staggered increases to the national living wage since 2016 have benefited new starters, senior staff with 5+ years’ experience have seen their pay advantage squeezed to just 6 pence per hour by March 2021.[48]

The intention behind the government’s Fair Cost of Care policy is welcome. However its impact assessment acknowledges that there are uncertainties regarding the extent to which staff will benefit, as at some providers the additional funding may only be “partially” passed onto staff through improved wages and working conditions.[49] In order to be effective local authorities must be funded adequately according to their cost of care exercises, with robust stipulations in commissioning and contracting. HMRC could assist by being more proactive in enforcing the minimum wage[50], particularly for homecare workers’ travel time between appointments.

4.4. Conditions and pay in the NHS

Drawing on our most recent research, this submission focuses mostly on recruitment and training of NHS staff. However, better performance in persuading existing employees to stay is also crucial to closing the gaps in the health service workforce. We anticipate other submissions will address key factors of pay, terms and conditions, pensions, and the leadership and culture of the health service.[51]

There is good evidence that a more diverse workforce is associated with better retention of staff. However, our report last year commissioned by NHS Employers showed signs of bias and unequal treatment are widespread, and reported discrimination has actually worsened. These troubling signs exist for many different potentially disadvantaged groups.

Changing this is likely to require better data which shows these issues in their full complexity; clarity and honesty about which interventions actually demonstrably work; and the money and skilled people to execute and evaluate them. This requires actions from a wide range of NHS and wider governmental bodies. [52]

Some groups defined by profession also do not consistently receive the same promises of better working conditions that are made to other NHS staff groups. We found this was particularly noticeable in our recent research on mental health clinical support workers.[53]

While the NHS People Plan included ambitions to “offer [NHS staff] flexible working from day one”, many jobs descriptions for mental health support staff stated that flexibility was expected from the successful candidate, with many setting out expectations to work unsociable hours over a seven-day week. Mental health support staff also experienced higher levels of physical violence and bullying/harassment from patients compared to all mental health staff. Staff survey data shows that just over one in four (27%) of them are satisfied with their level of pay.

These factors are detrimental to staff wellbeing, and can impact on retention rates. We recommended that a first step towards better valuing these staff would be to develop clear and consistent job titles and descriptions, and mapping out a clear career progression route. On top of this, providing appropriate support for flexible working, career development and pay would be welcomed.

Jan 2022