NWO0038

Written evidence from UNISON

Executive summary

• There is a large and growing shortfall of nursing staff in the UK, with particular concerns for areas such as district nursing and psychiatric nursing.
• As a result, patient safety is at risk, with nurses concerned that they are unable to ensure safe, dignified and compassionate care.
• UNISON believes that England should now legislate for safe staffing levels.
• Fragmentation, cuts and a flawed approach to workforce planning have caused many problems for the service in recruiting, training and retaining the nursing workforce.
• There are concerns about getting sufficient numbers through training, turnover rates are a problem, and attempts to reduce the use of agency staff have been handled poorly.
• NMC plans for future nurse education cannot be implemented without addressing the skills and knowledge levels of the existing nurses who will work alongside those from future cohorts.
• Some of these proposals appear to be an attempt to respond to operational capacity and resource restraints rather than being driven by the principle of maintaining standards.
• UNISON supports using pre-registration programmes to start to build knowledge of medicines and prescribing, but has concerns about system capacity. The union strongly opposes the removal of medicines management standards.
• UNISON is concerned by the slow progress in getting nursing degree apprenticeships off the ground, as they could be a lifeline for those priced out of nursing by the removal of the bursary.
• Employers are apparently reluctant to commit to apprenticeships because of concerns about costs. Some of these concerns could be alleviated by looking to the existing workforce, where there is great untapped potential among healthcare assistants and support staff.
• Allowing employers to use levy funds to pay for salaries and backfill would help, but the government must also provide funding to cover salary and/or backfill costs in the short term.
• UNISON would like to see the nursing associate role become both a stepping on and a stepping off point, but there is so far no hard evidence of the extent to which such posts will be created beyond the pilot employers.
• Big questions remain about skill mix and how nursing associates will sit within safe staffing developments. Nurse shortages mean there are dangers of nursing associate substitution and UNISON is not convinced that there are yet sufficient safeguards in place to prevent this.
• The union has no confidence in the government’s ability to deliver on its promises to create more than 15,000 extra training places for student nurses.
• As feared, removing the NHS bursary led to a drop in students applying for and taking up places on nursing courses. There are particular concerns for the future of smaller courses.
• Comparisons across UK nations show that greater funding encourages more applicants, and UNISON continues to support the idea of a living bursary or salary status for student nurses.
• The impending UK exit from the EU is potentially extremely dangerous for the future of nursing.
• The NHS is heavily reliant on European staff, yet the government has failed miserably to offer sufficient reassurance to these workers at a time of great uncertainty.
• The use of alternative language assessments is a broadly positive move, but it is also important to ensure that attainment levels across any future acceptable tests are equal.
• UNISON does not believe such moves will lead to a sufficiently large increase in migration; bigger barrier to foreign nationals migrating to the UK is the attainment level required in tests.

Introduction

1.      UNISON is the major trade union in health and social care and the largest public sector trade union in the UK. We represent more than 450,000 healthcare staff employed in the NHS, and by private contractors, the voluntary sector and general practitioners. In addition, UNISON represents over 300,000 members in social care. The union’s community and voluntary sector has an expanding membership of more than 60,000 and UNISON has a large retired membership of more than 165,000 with a particular interest in the future of health and social care. In addition, there is a wider interest among our total membership of 1.3 million people who use, or have family members who use, health and care services. This submission is structured around the terms of reference suggested by the inquiry and UNISON would welcome the opportunity to give oral evidence to the Committee.

Evidence on the current and future scale of the shortfall of nursing staff

2.      Before the EU referendum, official figures showed more than 23,000 vacant nursing posts across England, Wales and Northern Ireland – a shortfall that was predicted to persist until at least 2020.[1] Once Scotland is factored in, along with the impact of the impending UK exit from the EU, it is reasonable to assume that the number is now considerably higher than this. Estimates suggest a likely shortfall of around 40,000 with the government itself reportedly preparing for a gap of up to 42,000 in the near future.[2]

3.      The trend is certainly an upwards one, with the number of online adverts alone for vacant posts rising to nearly 11,500 in March 2017 from less than 10,000 last year.[3] And the shortfall shows no sign of improving any time soon: the latest figures show that for the first time more nurses and midwives are leaving the Nursing and Midwifery Council (NMC) register than joining it, with nearly 35,000 leaving in 2016-17.[4] 

4.      Although the Migration Advisory Committee has highlighted that shortages are worst in England[5], other parts of the UK have also suffered. Data published in September 2017 by NHS Scotland’s Information Services Division showed a record number of nursing and midwifery vacancies, with about one in 20 posts unfilled.[6]

5.      There are particular concerns from different fields of nursing. Analysts have pointed to dramatic cuts in district nursing, with a 44% drop in full time equivalents since 2010.[7] Primary care leaders have called for action to end the “20-year demographic timebomb” in practice nursing.[8] The Care Quality Commission (CQC) reported that in their 2016-17 inspections of the high secure hospitals in England all three had a shortage of nursing staff, and the CQC has repeatedly highlighted a 12% drop in psychiatric nurses across the NHS between 2010 and 2017.[9] This figure goes some way to explaining the alarming findings of UNISON’s recent survey of mental health workers, 87% of whom blamed staff shortages for a rise in violent attacks; a third of respondents are now having to work alone (compared to previously), placing them increasingly at risk of abuse.[10]

6.      The impact of nursing shortages has been profound and distressing. The efficiency of the NHS has been affected, with shortages contributing to the problems of delayed discharge.[11] But more worryingly, patient safety is at risk. For example, the recent CQC intervention at Stepping Hill Hospital in Stockport pointed to significant shortfalls in nursing staff including, on one ward, only one registered nurse to 13 patients.[12]

7.      UNISON’s annual nursing survey in April 2017 showed that chronic understaffing is now putting patient lives at risk – almost two-thirds (63%) of respondents reported that wards are so understaffed that nurses cannot ensure safe, dignified and compassionate care.[13] The union’s report showed that patient-to-nurse ratios are worst on wards for the acutely ill or injured, with 41% of nurses caring for eight or more people, the point at which patient safety is at risk according to NICE guidance. The report also revealed that half of respondents had to work through their breaks to make up for the lack of colleagues, and four in ten (41%) worked more than their contracted hours. This is leading to exhaustion and burnout, with more than half (54%) of respondents saying they would leave their current job if they could; one in ten said they want to leave nursing altogether.[14]

8.      Other studies have produced similarly worrying findings. More than one in eight nurses face barriers to working in a caring and compassionate manner due to the pressure they face in the health service, including staff reductions, according to researchers at the University of Birmingham. This is leading to “moral disengagement” and compromising their professional practice.[15] Working conditions such as staffing levels and workload were cited by 44% of respondents as their reason for leaving the register by a recent NMC survey.[16] The Health Service Journal published an analysis of safe staffing figures for community hospital wards, which showed nearly a third of trusts failing to meet their own targets for the past two years.[17]

9.      UNISON believes that England should follow the approach taken in Wales (and planned in Scotland) by legislating for safe staffing levels. Setting acceptable nurse-to-patient ratios would improve recruitment and encourage nurses to stay in the profession. There has been no shortage of international research over a number of years in support of such a move, and a 2017 study by the University of Southampton has found that a failure to deliver complete nursing care explains why hospitals with lower registered nursing staff levels have a higher risk of patient death. Care left undone due to lack of time is described as the “missing link” in understanding variation in mortality rates in hospitals: when staffing is lower necessary care is more likely to be missed, with each 10% increase in the amount of care left undone associated with a 16% increase in the likelihood of a patient dying following common surgery.[18]

The effectiveness of government and arm’s length body plans to recruit, train and retain the nursing workforce

10.  There is a growing consensus that a combination of fragmentation, a flawed approach to workforce planning and government cuts have caused many problems for the NHS in recruiting, training and retaining the nursing workforce. The National Audit Office (NAO) criticised the lack of proactive workforce planning in 2016 as it called for “a more coordinated and proactive approach to managing the supply of staff” which “could result in efficiencies for the NHS as a whole”. It pointed out that “central oversight and intervention are needed to ensure that decisions are sufficiently strategic and made for the benefit of the overall system”.[19] The health secretary himself acknowledged recently that “workforce planning has been woeful” for a long period of time, with successive health secretaries too short-termist in their approach.[20]

11.  The fragmented nature of the English NHS, particularly since the passage of the Health and Social Care Act in 2012, has not helped; the NAO found that “the arrangements for managing the supply of clinical staff numbers are fragmented, increasing the risk of duplication and incoherence”.[21]

12.  A further finding of the NAO was that “trusts’ workforce plans appear to be influenced as much by meeting efficiency targets as by staffing need”[22], pointing to the damaging impact that austerity has had on the ability of the NHS to put in place robust staffing arrangements. More recently, the chief executive of NHS Employers called for national cuts to continuing professional development (CPD) to be reversed as part of measures to tackle urgent problems with staff retention, highlighting government “disinvestment” in Health Education England (HEE).[23]

13.  There are concerns about the inability of the system to get sufficient numbers through training. To quote a recent example, the Queen’s Nursing Institute recently revealed that almost all district nursing course providers have “major concerns” about the future funding and viability of their programmes.[24]

14.  Turnover rates are a particular problem in the sector. In community trusts, for example, NHS Improvement has revealed that there was a turnover rate of more than 14% in 2016, representing a “significant challenge” for community providers.[25] And in mental health, the CQC links high turnover rates to staff shortages and sickness absence, stating that “the resulting negative effect on morale can create a cycle of increasing sickness and further staff turnover that can be difficult to break”.[26]

15.  National attempts to reduce the use of agency staff have often been handled poorly. As a basic principle UNISON supports the idea that NHS funding should wherever possible be spent on employing substantive staff, rather paying higher rates for temporary fixes. However, providers will always need to have access to temporary staff to plug gaps in capacity, and ideally this should be done through staff banks rather than by paying extra to private staffing agencies. This made the abortive government attempt to sell off 75% of NHS Professionals such a puzzling decision. As a publicly owned NHS staffing agency, NHS Professionals was set up to save on the high costs of using private staffing agencies and saves the NHS more than £70m a year by supplying 88,000 agency doctors, nurses and other health professionals to health services across the UK, with all profits reinvested back into the NHS. UNISON is glad that the government saw sense by abandoning the sale in September 2017. It is also unreasonable to blame staff for opting to take up temporary opportunities at a time when staff pay across the sector has suffered such a slump in value since 2010. UNISON was grateful that NHS Improvement backed away from its original decision to prohibit substantively employed staff from seeking agency work earlier this year.[27]

16.  This wider issue of nurse pay is probably the single greatest problem affecting the ability of the NHS to recruit and retain sufficient nurses; this was the main reason cited by mental health workers who are considering leaving their jobs in UNISON’s recent survey.[28] Nurses have gone without a proper pay rise for far too long, with their wages continuing to fall behind inflation as food and fuel bills, housing and transport costs rise. Given the way the NHS Pay Review Body has had its hands tied by the government’s 1% cap on public sector pay, UNISON and the other NHS trade unions broke with tradition in September 2017 and submitted a pay claim directly to the government. The unions urged the Chancellor to earmark funds in the forthcoming Budget for a pay rise in line with inflation coupled with an additional £800 payment per individual to restore some of the pay lost over the past seven years. Nurses need a pay award that stops the deterioration in value of their wages and starts to restore some of the earnings they have missed out on. A decent pay rise will make it easier for struggling trusts to attract new recruits and hold on to experienced staff. UNISON is also clear that there must be no selective lifting of the cap; all public servants deserve a proper pay rise, regardless of where they live or what job they do. The campaign for fair pay has been buoyed by recent opinion polling that showed an overwhelming majority of the public (84%) support the removal of the cap on pay rises for NHS staff.[29]

The impact of new routes into nursing

Changes to nurse education

17.  UNISON believes that the NMC’s programme of change for education cannot be implemented without addressing the skills and knowledge levels of the existing nurses who will work alongside those from future cohorts. Their initial education will have been quite different. This will prove particularly challenging to address unless the current cuts to budgets for CPD are reversed.

18.  We are concerned that some of the NMC’s proposals appear to be an attempt to respond to operational capacity and resource restraints, rather than being driven by the principle of maintaining standards. In particular, the proposal to allow substantially more practice learning to take place through simulation appears to be a response to the current strain on practice placement capacity, with no positive rationale put forward for why and how the figure of 1,150 hours was arrived at. Similarly we are concerned that removing prescribed proficiencies and training requirements for mentors will lead to cost and corner-cutting, driving further inconsistency in standards. It will also make it more difficult for nurses to secure the time and funding they need to train and prepare for mentor/assessor roles. The current funding environment means that cost considerations are likely to be the driver, rather than creative and innovative approaches driven by quality considerations.

19.  The programme does not consider how the changes will impact on preceptorship. There is a danger that nurses educated to the new standards will be seen as having higher level skills and being able to do more from the point of qualification. This could have the effect of eroding preceptorship and opportunities for specialist and advanced practice.  In fact the changes will mean there is a greater need for ongoing supervision, reflective practice and support.

20.  UNISON believes that cultural competence, understanding and confidence should be at the core of all nursing and midwifery education and that the NMC should therefore have placed a greater emphasis on all the protected characteristics in the Equality Act 2010. This would allow for nurse education to explore innovative ways to learn how to work, treat and care for diverse groups and individuals. It would also be likely to attract people from diverse backgrounds to nursing.

21.  It is clear that there are still significant shortfalls in the support students receive – especially those with particular learning support needs. UNISON is concerned that with the greater demands of the proposed new standards and the attempt to squeeze more content into degree programmes, these shortfalls could get worse.

22.  UNISON is concerned that the changes proposed will create uncertainty about who will have responsibility for setting standards for assessors and how this will take place. There is a considerable risk of inconsistency. Clarity is needed about how this will be monitored, audited and evaluated. We believe that it is vital that there is a shared benchmark for deciding what makes assessors competent to assess students and whether they have currency of knowledge and experience.

23.  UNISON supports using pre-registration programmes to start to build knowledge, theory and understanding of medicines and prescribing. However, we have serious concerns about whether there is sufficient capacity within the system for this to happen to a consistent standard. The union does not support moves to allow nurses to start community prescribing programmes immediately post-qualifying, as new graduates need time to establish themselves in their new roles. Reducing the time from three to one year post-qualifying for independent prescribing also appears risky and should depend on setting, supervision levels and overall competence. 

24.  The proposed removal of medicines management standards is something that UNISON strongly opposes, as it will produce inconsistency and weaken the hand of registrants. Registrants need clarity about their role and function in this area; the current NMC standards inform and underpin local policies, helping registrants to raise concerns locally.

Nursing apprenticeships

25.  In November 2016, Jeremy Hunt announced that nursing degree apprenticeships would launch in September 2017 and there would be up to 1,000 nursing degree apprentices starting each year. Progress has, however, been extremely slow. It was announced that nine further universities will offer nursing apprenticeships from September 2018 to go with the first wave of four who received money from the Higher Education Funding Council for England (HEFCE) with a view to offering courses from September 2017. However, Nursing Times found that none of the first wave has so far been approved by the NMC, delaying the start of their courses. Only the Open University and Anglia Ruskin University are currently approved to run degree-level nurse apprenticeships, neither of which received money from HEFCE.[30] In addition, the number of apprentices enrolled is reportedly very low.[31]

26.  UNISON is very concerned at the delay in getting nursing degree apprenticeships off the ground. We believe this route could provide a lifeline for those aspiring nurses who find themselves priced out of the traditional student route by the government’s policy of removing the bursary and making students pay tuition fees.

27.  While part of the delay may be in the processes needed to design programmes and secure NMC approval, UNISON has heard from employers that they are reluctant to commit to apprenticeships because of concerns about costs. Many employers would in principle want to support apprenticeships because “grow your own” schemes have a good track record of widening participation and retaining staff with strong local roots once they qualify. But it appears that employers are concerned about having to pay salary costs for up to a four year period.

28.  This is because the apprenticeship levy only pays for tuition fees while employers must cover salary costs from existing budgets. An apprenticeship must be a genuine job, but NMC requirements for the awarding of nursing degrees are for the completion of 4,600 hours of learning. Half of this must be theoretical learning, and half must be practice learning. The NMC says apprentices, like student nurses, must be treated as supernumerary during practice learning. However, unlike student nurses, apprentice nurses must have a contract of employment covering all the hours they spend working and learning. The effect of this is that – once annual leave and public holiday entitlements are taken into account – an apprentice will need to spend 25 hours a week undertaking theoretical or practical learning. This means they can only be part of the staffing establishment for 12.5 hours a week. The employers UNISON has heard from have concerns that this makes the apprenticeship route expensive.

29.  The union believes that some of these concerns could be alleviated if employers look to their existing workforce. There is great untapped potential in the healthcare assistant (HCA) and support workforce. Our most recent survey of members in these roles showed that nearly two-thirds would like to train to qualify as a nurse or other health professional.[32] Through accreditation of prior experience and learning (APEL) we believe many of them could be slotted into the apprenticeship programme on a faster track. This would bring the required number of hours down and allow them to be available for more hours and/or to complete the programme quicker than the four years. Short bridging programmes, such as that developed by Skills for Health[33], could be used to provide the study skills that some candidates would need to facilitate entry into higher education.

30.  However, it remains unclear to UNISON and employers how the APEL process could be made to work most effectively, as different universities have different approaches, with prior experiential learning not given sufficient weight. For example, an HCA with ten years’ experience in A&E may receive little or no credit for their experience, skills and knowledge.

31.  Through its widening participation agenda HEE has provided some employers with funding to support flexible pathways into nursing in the form of “grow your own schemes” but it is unclear as to whether these funding streams will continue beyond current cohorts.

32.  UNISON would like to see a thriving apprenticeship route into nursing but we believe that additional funding will be required. A change to allow employers to use levy funds to pay for salaries and backfill might assist with this. However, we firmly believe that for apprenticeships to take off, the government will need to provide central funding to cover salary and/or backfill costs in the short term.

Nursing associates

33.  The nursing associate pilots are in the early stages and there is no hard evidence of the extent to which posts will be created beyond the pilot employers themselves. The nursing associate should be both a role with career prospects in its own right, and a possible stepping stone into registered nursing. However it is not clear how much APEL a qualified nursing associate will get towards the nursing degree. Current NMC rules restrict APEL to 50% of the degree. It is also not clear whether a period of preceptorship in a nursing associate role will be required first or whether a qualified nursing associate could move straight into nurse training. UNISON would like to see the role becoming both a stepping on and a stepping off point so that someone who is not able to complete their nursing degree programme would have the option of stepping off as a nursing associate.

34.  Big questions remain about skill mix and how nursing associates will sit within safe staffing developments. UNISON continues to believe that the current shortage of nurses means there are dangers of nursing associate substitution. We are not yet convinced that there are sufficiently robust safeguards to prevent this happening on the ground. There is evidence of some Sustainability and Transformation Plans seeking to cut back on their nursing spend by expanding the use of other roles.[34]

The effect of changes to funding arrangements for nurse training

35.  UNISON notes health secretary Jeremy Hunt’s announcement at the recent Conservative Party Conference of an extra 5,000 training places for student nurses (on top of previous promises), to be made up in part by tripling the number of nursing associates. However the union has no confidence in the government’s ability to deliver such a commitment.  To begin with, the funding for the package is not entirely clear, with suggestions that part of it would be dependent on securing funds in the forthcoming Budget. Moreover, the demise of the NHS bursary means that government no longer commissions training places directly, depending instead on universities in the free market creating extra places and recruiting the students to take them up. There is so far no sign of realistic progress towards achieving the government’s previous claim that the new system would lead to 10,000 extra places, with some universities suggesting as recently as June 2017 that the government was quietly reneging on its promise to expand training places.[35] Training providers have also highlighted the differences between promising to expand places and actually delivering it, saying that “people must want to follow a career in nursing and see it as an attractive sector”.[36] There remain unanswered questions about how NHS providers will accommodate such a large influx of extra trainee nurses, with a need for mentors and supervision to help with on-the-job learning. While welcoming Hunt’s announcement, the Council of Deans of Health said that it needed to be accompanied by adequate investment in the existing workforce to expand training capacity.[37]

36.  As UNISON and others predicted, the removal of the NHS bursary led to a slump of 23% in applications by students in England to nursing and midwifery courses.[38] This ultimately translated to a drop in students with a place on a nursing course in England of 6% compared to 2016 after clearing in September 2017.[39] This came despite the introduction of last minute government financial incentives, which universities said came too late for them to recruit more students.[40]

37.  UNISON pointed out on many occasions, including to the Health Committee[41], the folly of ending the NHS bursary. Opinion polling by YouGov for UNISON demonstrated overwhelming public support for the union’s position that the government should carry on paying the tuition fees of healthcare students (77%) and that healthcare students should be paid for the work they do (71%).[42]

38.  A study by London Economics for UNISON and the NUS found that the abolition of the bursary will leave most student nurses with more than £50,000 worth of debt, discouraging many from training and worsening shortages. In addition, the report concluded that higher education institutions will suffer financially as a result of the bursary being scrapped, and that the cost savings to government are likely to be far less than suggested, if they materialise at all. [43] 

39.  The government failed to undertake any assessment of the potential impact of the changes on the number of students actually completing their course. The Shape of Caring review[44] found that attrition rates on nursing degree courses are in excess of 20%. A 2016 UNISON report argued that to reduce their exposure to debt, student nurses may be more likely to take on additional working hours outside of their studies and placement.[45] Such long hours are known to affect the ability of students to study and so have an impact on their final qualification levels. Attrition rates may therefore increase because students are too burnt out to complete the course or get the required grades.

40.  Many current students and the nurses who mentor them are raising concerns about the fact that students are routinely being deployed to fill in for HCA shortages. This is particularly a problem for students who have previously worked as HCAs and for students who also work bank shifts as HCAs. This means that they are not exposed to the range of learning opportunities that they should be getting, and the sense of inequity around this will only grow now that students in England will be fully funding their education through student debt.

41.  UNISON and others warned about the impact of removing the bursary on smaller courses (and those that tend to attract mature students). Worrying evidence of this is beginning to emerge with London South Bank University forced to cancel its learning disability nursing course due to a 75% reduction in applications following the loss of the NHS bursary.[46]

42.  Early UCAS figures for 2017-18 courses showed the difference in nursing applicants across England, Scotland and Wales and it was noticeable that, while there was a decline across all three countries it was far more pronounced in England: 23% compared to 9% in Wales (where the bursary has been retained with conditions) and 4% in Scotland (where the bursary has been retained without conditions). [47] Put simply, more funding encourages more applicants – one of the reasons UNISON continues to support the idea of a living bursary or salary status for healthcare students. Wales is continuing to provide NHS bursaries in 2017-18 and will undertake a review to determine future methods of funding healthcare education. It is a matter of regret that a compromise of this sort to provide a breathing space was not even contemplated for England.

The impact of EU exit and language testing

43.  UNISON has been consistent in its warnings about the impact of exiting the EU on the NHS and social care, and academics continue to point to the damage that will be done.[48] The revelation in January 2017 that there had been a 92% drop in the number of EU nurses registering with the NMC since the referendum vote[49] should have been a wake-up call to everyone in government about the serious consequences that lie ahead. Subsequent Health Foundation figures suggested an even greater fall of 96% between July 2016 and April 2017.[50] The number of nurses from EU countries leaving the NHS increased by 38% last year compared to the previous 12 months[51] and a mere 46 European nurses registered with the NMC in the month of April 2017.[52]

44.  The workforce of the NHS is heavily reliant on European staff. The Health Secretary said in his conference speech that the government was confident EU workers in the NHS would be able to stay with the same rights that they have now. This is painfully inadequate. The government should have moved early on to provide reassurance by guaranteeing the rights of all EU staff to remain working in the NHS – and across the public sector – post-exit. If they felt unable to do so then, they should now correct this as a matter of urgency so as to avoid worsening the already dangerous shortage of nurses.

45.  The union is seeking a number of commitments from the UK and the EU. These include keeping the current rights of EU citizens in the UK and British citizens in the EU; guaranteeing these rights for life subject to international law and the Court of Justice of the EU; ensuring that people are not used as bargaining chips in negotiations and are protected regardless of the outcome; introducing a free, easy to use registration process for EU citizens in the UK; and, crucially for the future of UK nursing, maintaining in full the rights to freedom of movement and residence for EU citizens in the UK (and British citizens in the EU).

46.  The NMC has been consulting on whether to use the Occupational English Test (OET) as an alternative to the International English Language Testing System (IELTS) – the latter is recognised as being too expensive, which is affecting the recruitment of foreign nationals into nursing. The use of language assessments other than IELTS is a broadly positive move, but it is also important to ensure that attainment levels across any future acceptable tests are equal. UNISON is concerned about the variable availability of alternative testing methods; there are, for example, fewer OET test centres than IELTS ones.

47.  The NMC has also been looking at changing its rules so that all nurses who have trained in English, as well as those who have practised for two years in an English-speaking country, are no longer required to pass the IELTS – currently this only applies to EU nurses. Making the requirements uniform is a positive step, but it is important to accept that those from less affluent countries – that supply the largest number of migrant workers to the UK – will potentially be unaffected by this change. With applications from EU citizens dwindling since the referendum vote, it is optimistic to believe that accepting more migrants who have been taught in English will address concerns about shortages. This also raises issues around ethical recruitment from overseas and the broader impact on countries where nurses did their training.

48.  UNISON does not believe that such moves will lead to a significant increase in migration to help ease the staffing crisis. The biggest barrier to foreign nationals is not the evidence required but the level that needs to be attained. In countries where IELTS will remain the primary means of testing – even where other methods of testing may be available – the current requirement to achieve level 7 is too high. (Some British born nursing students also have difficulty passing IELTS 7.) Currently other native English-speaking nations such as Australia and the USA require an overall IELTS score of 6.5. Bringing the UK into alignment with these countries would significantly alleviate many of the current problems prospective migrants face.

49.  The NMC should investigate the possibility of opening up the process to include foreign nationals who are already working in the UK who have failed IELTS (or Objective Structured Clinical Examination) previously – many of whom end up working in social care and would welcome the opportunity to re-enter their desired profession as a nurse. There may after all be a number of reasons for this, such as the fact that in India and the Philippines most secondary and tertiary education is taught in English, but the English learnt via textbook is vastly different to colloquial English in the workplace, with some nurses struggling with regional British accents for example. Some of these people may also have studied in the UK in health and social care courses for more than two years and have gained UK qualifications, sometimes in health and social care management, which should also be considered.

Submission produced by the UNISON Policy Unit

October 2017

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