Written evidence submitted by the Royal College of Nursing
Royal College of Nursing submission: Education Select Committee Inquiry, The impact of COVID-19 on education and children’s services, July 2020.
The Royal College of Nursing (RCN) is the largest professional body and trade union for nursing staff in the world, with around 450,000 members across the UK.
This submission focuses on three main points:
COVID-19 presents a number of risks to higher education for nursing students, risking supply:
Due to the wide-ranging interdependencies of increasing nursing supply, not all issues raised here are fully in the remit of the Department for Education. It is vitally important however that all are addressed, and the Department acts as a leader bringing together all relevant bodies and cross-government departments to increase and safeguard nursing supply in England.
We are concerned that COVID-19 will have long-term implications for future nursing supply, which will only exacerbate the current workforce shortages. Before the pandemic there were at least 40,000 nursing vacancies in NHS settings across England alone; a vacancy rate of 10.7%.[i] A lack of adequate supply causes unsafe staffing levels, risking the quality of care patients receive. Any reduction in workforce supply will undermine the Government’s commitment of 50,000 more nurses in England’s NHS by the end of this Parliament.
In addition, during the pandemic, our members have described difficulties in sending their children to school as part of the critical workers policy. This is caused by a lack of school provision and poor communication from Government and local authorities. These issues must be addressed in preparation for a potential second peak.
Our School Nurse and Health Visitor members are seeing the negative effects on children’s early development that has been caused by the pandemic. This includes difficulties with remote consultations, vaccination rates and increased use of food banks. Addressing these issues will require an increased supply of specialist nurses working as part of a team alongside social workers and mental health nurses.
Underinvestment in the nursing profession
The NHS vacancy rate reflects years of nurses being undervalued - resulting in too few people pursuing a career in nursing and too many leaving the profession.
In 2016, the Government introduced a series of reforms to the planning and funding of nursing higher education in England. These reforms moved from a centrally commissioned model, where the number of nursing degree places were set centrally and students did not have to pay tuition fees, to a ‘market’ model, where there were no set limits on the number of university places, but students had to self-fund their tuition fees. These reforms also removed the modest bursaries paid to nursing students for living costs.
These reforms were meant to increase the number of new nursing students in England. In practice they have had the opposite effect. The number of people applying to nursing courses in 2019/20 was 31% lower than at the same time in 2016/17, the final year of the old funding model. And the number of people accepted onto places was 4.1% lower over the same time period.
This is why, as part of a wider package to support attraction into and retention of the nursing profession, we call for the Government to:
Our forthcoming report, Beyond the Bursary, outlines how the Government can increase the supply of nurses in England by implementing new student funding models. This report shows the negative impact of the removal of financial support in 2016 on workforce supply, including testimonials from “missing nurses” who were put off studying nursing by the prospect of a lifetime of debt.
Potential new nursing students may be deterred by the pandemic
The COVID-19 pandemic has disproportionately affected Black, Asian and Minority Ethnic (BAME) communities and clinicians from BAME backgrounds have died at a higher rate than their White British counterparts.[ii]
Importantly, BAME nurses have also signalled their alarm at the scale of the risk that they are required to take, often without the support of their organisation to provide care safely. The cumulative impact of these factors lessens the overall appeal of nursing as a viable profession.
Our research shows that BAME nursing staff are more likely to have problems accessing protective equipment.[iii] For example, for nursing staff working in high-risk environments (this includes those working in intensive and critical care units), less than half (43%) of respondents from a BAME background said they had enough eye and face protection equipment. This is in stark contrast to two-thirds (66%) of White British nursing staff.
The way in which COVID-19 has disproportionately impacted people from BAME backgrounds may be off-putting for prospective students from these groups. Every effort must be taken by the Government, universities and employers to reassure prospective and current BAME students, as well as lecturers and nursing staff, that their safety is paramount.
Clinical placement capacity
Each nursing student must spend at least 2,300 hours, or 50% of their course time, in clinical placements in a range of clinical settings. Universities are only able to offer as many nursing degree places as there are corresponding local clinical placements. This can create a significant bottle neck in attempts to increase the number of students.
The availability of clinical placements could be impacted by COVID-19, as there may be less resource available in health and care settings to offer placements. There may also be regional differences in the availability, due to the differing numbers of infections across England and the regional responses required. Therefore, the Department for Health and Social Care, Department for Education and the associated arms’ lengths bodies, including NHS England and Health Education England, must work to establish a national database of clinical placements that considers national and local capacity, ensuring that all eligible students who wish to study nursing can do so.
Potential delays to the start of the 2020/21 academic year
The moves to online learning have been largely successful for most nursing courses. However, the nature of a nursing degree means that online learning is unlikely to be sufficient long-term. Teaching relies on classroom-based delivery as complex information is presented and skills are learnt. Some students will struggle with the demands on their mental health that learning from home may bring, on top of a challenging degree. We are also concerned about the move to remote learning on a range of other groups such as students with a disability, who may struggle to have the level of learning support and equipment they need in their home environment.
Simulation training, for example, in which students work in simulated real-life situations, often on dummies, is a critical part of a students’ learning and is impossible to emulate online. Moreover, nursing schools and campuses, as well as the educational syllabus, are not set up for social distancing and this could limit any moves to return to physical classes.
Any of these risks could lead to universities delaying the start of the 2020/21 academic year. The Department for Education and relevant public bodies should work with universities to ensure that all measures are taken to minimise disruption so that nursing schools have the necessary infrastructure, capital, human and technological equipment to ensure that the 2020/21 academic year starts on schedule. There is also a risk that a large number of students will chose to defer the beginning of their studies due to COVID-19, also causing supply issues in future academic years.
Many nursing schools provide little marginal financial benefit for university administrations due to the high costs of course provision. Some extra grant funding is provided to universities to ensure that the provision of nursing courses remain a viable proposition.
There is still however some cross-subsidisation within universities to fund less profitable courses such as nursing. This could make nursing course provision vulnerable should universities face financial deficits following the crisis.
We expect the Department for Education to work across Government to address any shortfalls in university funding to ensure that no nursing course is placed at risk. While it was welcome news when the Office for Students recently announced that the planned decrease to nursing teaching grants has been paused, these funding levels reflect a pre-emergency environment. Urgent work must be undertaken to fully and appropriately assess what funding is required to support the increases in nursing graduates needed to provide safe and effective care for all patients.
Cancellation of A-Level exams
Nursing takes its strength from its diversity; the profession reflects and learns from the cultures, traditions, faiths and customs that shape and promote health and wellbeing across the communities and populations that it serves. The Department for Education and associated regulators must ensure that the cancellation of A-Level exams does not undermine efforts to widen participation and maintain a diverse nursing student population. The Runnymede Trust recently wrote to the Secretary of State for Education highlighting their concerns that use of predicted grades could result in certain groups, including BAME students, facing an unfair disadvantage.[iv]
The proposed method of replacement grading should be closely monitored for negative effects on widening participation targets by the Department for Education, the Department for Health and Social Care and higher education regulators. It is our recommendation that this process undergoes a regular equality impact assessment and where clear disadvantage or bias is found, then urgent and thorough action to mitigate harm and disadvantage are swiftly taken by the relevant bodies.
Apprenticeships – nursing degrees and nursing associates
Apprenticeships have been identified as a priority for nursing supply in both the NHS Long Term Plan and the Interim People Plan. Nursing associates and nursing degree apprentices are largely drawn from healthcare assistants. They are therefore more likely to have had their studies disrupted due to COVID-19. We expect higher education institutions to work closely with apprentices to ensure the minimal amount of disruption to apprentices learning.
We also expect the Department of Education, in conjunction with relevant health and care bodies, to take all necessary measures to ensure that higher education institutions and employers have the funding and regulatory environment to continue to facilitate the restarting of apprenticeships when it is safe to do so.
Nurses are critical workers and have been unstinting in their dedication to patient care during the pandemic. However, many members have reported that they struggled to access the support available to key workers. The biggest problem has been with school provision. The geographic spread of school services has been limited by, among other things, the number of teachers available during the pandemic. This has been particularly the case for pre-school nurseries and special schools that cater for children covered by education, health and care plans (EHCPs) e.g. children with autism and/or learning disabilities.
Anecdotally, some nursing staff report that they have been told they cannot send their children to school because their partner is not a key worker. This is often against official guidance and without due consideration about the capacity of the partner to care and home school. In addition, where schools have been unavailable in their area, many members report that they have been unwilling to send their children to new schools owing to concerns around the children’s emotional wellbeing.
These issues have been exacerbated by inconsistent communication from central Government, local authorities and schools about which schools are open and which children can attend. Anecdotal evidence suggests that some schools and local authorities have been issuing guidance that contradicts government guidance. This creates undue stress and an emotional and administrative burden on nursing staff trying to use this support.
Finally, the lockdown restrictions mean many family and friends of nursing staff can no longer help with childcare. Nursing staff who rely on this help have been left unable to work. This is particularly the case for staff who work shifts that do not fit neatly with a school day. For example, a nurse starting a 12-hour shift from 7am to 7pm is unable to pick up their children at the end of the school day. This has been compounded by a lack of employer flexibility on shift patterns owing to the workforce pressures caused by COVID-19.
All of these issues combined undermine the ability of nurses to contribute to the emergency. In future outbreaks we would expect a more comprehensive coverage of school provision for all key worker children and parents. This includes geographic distribution of types of schooling and flexibility for parents working shifts; and funding should be made available for childcare for parents that work longer hours than the school day covers. Finally, we would expect a much more comprehensive communications plan from Government.
The impact on children’s early development
Health Visitors primarily work with children and families from pregnancy to five years. School Nurses work with school aged children, their families and schools. Members from both categories have been working in their communities throughout the pandemic.
COVID-19 has necessarily restricted these nurses to mostly remote consultations. However, not all families have access to the technology needed for video consultations and this limits the effectiveness of health visitor consultations; for example, around identifying risks to child protection. This digital exclusion is one of many symptoms of inequality made worse by lockdown. A lack of space, an inability to social distance in overcrowded and/or temporary accommodation can negatively impact children’s development.
Perhaps most worrying is the evidence on the impact to the routine vaccine programmes: there was a significant reduction in vaccination rates in England in March and early April.[v] Exposure to preventable disease during childhood can have lifelong effects. We urge the Government to identify those children who have missed their vaccinations.
A joined-up approach is needed to avoid the same mistakes again
COVID-19 has made clear that complex issues of children’s development require a joined-up approach between different professional and government agencies. As schools and life return to normal there will be an even greater need to consider the wider emotional and social impact of COVID-19 on top of existing issues to children’s health and wellbeing.
Having the right number of staff will be key to a joined-up approach. The Department for Education has committed to a social worker in every school. We believe that this is a positive step. However, the Government must go further if it is to mitigate the effects of COVID-19 on children and young people by creating a comprehensive team of support workers.
This cannot happen if there are not enough staff. We are aware of some School Nurses covering up to 12 schools and this shortage has been made worse by the pandemic as many School Nurses have redeployed to help in acute settings.
An effective joined-up approach should have school nurses working alongside CAMHS mental health nurses and children’s community nurses. We know that currently there are too few community and mental health nurses and the Government must address these shortages through funding for university training and fair pay.
Combined, these professions can provide emotional support, health promotion advice and support to the vulnerable children and young people who need them most; they will also be able to advise on infection prevention and control. Achieving this will require a collaborative approach from the Department for Education, the Department of Health and Social Care, local authorities and children’s social services.
[i] NHS Digital –NHS Quarterly Vacancy Statistics – February 2020 available here: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey
[ii] Public Health England, Disparities in the risk and outcomes of COVID-19, available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892085/disparities_review.pdf
[iii] Royal College of Nursing, RCN COVID-19 Staff Testing Survey Findings, available at:
[iv] Runnymede Trust, Open Letter: Predicted grades & BME students, available here: https://www.runnymedetrust.org/blog/predicted-grades-bme-students-letter-to-ed-sec
[v] See McDonald H, Tessier E, White J, Woodruff M, Knowles C, Bates C, Parry J, Walker J, JA Scott, Smeeth L, Yarwood J, Ramsay M, Edelstein M (2020): Early impact of the COVID-19 pandemic and social distancing measures on routine childhood vaccinations in England, January to April 2020 Eurosurveillance Vol 25, (19), 14/May/2020 https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.19.2000848