Written evidence from NHS Employers
About NHS Employers
NHS Employers is the employers’ organisation for the NHS in England. We help employers to develop a sustainable workforce, improve staff experience and be the best employers they can be. Our practical resources and expert insights make sense of current and emerging healthcare issues, to keep employers up to date with the latest thinking and ensure they are informed and equipped to support the NHS workforce.
We generate opportunities to network and share knowledge and we actively seek the views of workforce leaders to make sure their voice is front and centre of health policy and practice. We also lead the national collective relationships with trade unions on behalf of the NHS and the Secretary of State for Health and Social Care. NHS Employers is part of the NHS Confederation – the membership body that brings together and speaks on behalf of organisations that plan, commission and provide NHS services in England, Northern Ireland and Wales.
This paper sets out to evidence what action has been taken by employers in the NHS to address long-term supply and vacancy problems in the NHS nursing workforce, what impact the COVID-19 pandemic has had on current and future plans, and what would help to address the nursing shortfall in the NHS.
Addressing the nursing shortfall would not only be beneficial to the NHS, it would also enable anchor institutions like the NHS to be part of the solution to local and national economic recovery post-COVID-19, address skills gaps, and provide opportunities within communities that may not have considered the NHS as a career option.
The number of nurses working in a hospital or community setting in England has risen by 5 per cent between September 2010 and September 2019. Roughly 320,000 of the 590,000 people registered to work as a nurse in England work in hospital and community settings. 
Of the 660,213 nurses on the Nursing and Midwifery Council’s (NMC) register, 77.1 per cent are registered as adult nurses – a 2.4 per cent increase on 2015, 7.5 per cent are registered as children’s nurses – a 9.3 per cent increase on 2015. There has been a fall of 0.5 per cent in mental health nurses and a fall of 5.8 per cent in learning disability nurses as a percentage of the NMC’s overall registration.
The NMC’s data also shows that 84.5 per cent of the total number of registrants are first registered in the UK. 79.5 per cent of nurses and midwives on the NMC’s register qualified in England.
The number of nurses training in the UK have increased year on year for the last three years and in 2020 there were 35,960 applicants to nursing and midwifery courses. This is a 6 per cent increase on 2019.
Concerted action has been taken to tackle the shortfall of nurses domestically, with employers making best use of the new and emerging nurse degree apprenticeships and the initial successes of the nursing associate role, first piloted in 2017. HEE has recently tendered for education establishments to provide a blended learning nurse degree course, which they are aiming to start in 2021 and would allow students to participate in the academic part of the course via distance learning, therefore providing another route into nursing.
Work to encourage return to practice has also continued, and the response during the COVID-19 outbreak has seen more than 13,000 former or overseas nurses and midwives added to the Nursing and Midwifery Council’s temporary register to assist. NHS organisations and integrated care systems are exploring retention opportunities for some of these staff as appropriate.
In 2019, NHSEI launched a clinical placements support programme, which included 142 trusts working together with their local HEIs to increase undergraduate student placement capacity. As a result of the financial investment and efforts across the system, more than 7,500 extra nursing placements were provided. Due to this success, a second phase of the programme was announced on 29 June 2020, which is anticipated to increase placement capacity further. In June 2020, HEIs bid for a proportion of 5,000 additional nurse and allied health professional degree placements, in addition to the normal 5 per cent increase in courses already allowed.
In addition to this, from September 2020, students studying nursing degrees and other allied health professions will receive an annual payment of at least £5,000 that will not need to be repaid. There is also up to an additional £3,000 available to students, which applies to specialisms such as mental health nursing, or regions struggling to recruit, or to help students to cover childcare costs. This will support more than 35,000 students who will go on to work across health and social care. These are all positive incentives that will help employers across the NHS to reduce vacancies and secure the nursing workforce needed for the future.
This is a key area of focus at a national level to support the international recruitment of nurses, with overseas nursing supply likely to be a key component of the forthcoming NHS People Plan. Migration policy must continue to support this aim to recruit overseas staff, in line with the government’s manifesto commitment to deliver 50,000 more nurses. The impact of Brexit remains a concern for nursing. Nurses and health visitors are the only staff group to record a fall in the number of recorded EU nationals since the EU referendum, also falling from 7.4 per cent of the workforce in 2016 to 6 per cent in January 2020.
Non-EEA nurses continue to provide a vital pipeline that must be maintained, with the percentage of nurse joiners from outside the EEA increasing from 7.6 per cent in 2016 to 22.4 per cent in 2019.
NHS Employers and the Department for Health and Social Care worked with the Home Office to change visa timescales/extend visas. The Home Office has put in place temporary measures to extend the visas of all regulated healthcare professionals across the NHS and the independent sector during the COVID-19 outbreak. These measures initially applied to nurses, doctors and paramedics and were further extended on 29 April 2020.
Despite more recent focus on national workforce strategies and local efforts to attract and train domestically, training our own staff does not offer a quick supply solution and both immediate supply pipelines and training now face additional setbacks because of COVID-19.
Arm’s-length bodies and employers in the healthcare sector continue to highlight the challenges of hiring to key roles already on the shortage occupation list, and the necessity of their continued presence on the list. This includes nurses, who were added to the list in 2017. Without the salary exemption afforded in the current system for key roles, the sector would not have been able to recruit the 5,000 non-EEA trained nurses it did in 2019.
Employers remain deeply concerned about shortages in the social care workforce and the implications for the communities both sectors serve, as well as the knock-on effect for the health service and its patients. Social care continues to face a high vacancy rate, with workforce estimates from Skills for Care putting this at 122,000 (7.8 per cent of the workforce) during 2018/19. Concern is focused in particular around support roles, which form a greater part of the social care workforce. When freedom of movement ends from January 2021, overseas supply will effectively be cut off for these vital key workers and the impact on the provision of social care cannot be underestimated. We wrote to the Prime Minister on 15 July to ask that government looks at ways to ensure that this global pipeline can continue to support the social care sector, while the government puts in place its long-term plan for social care.
Employers have embraced the use of apprenticeships since the levy was introduced in April 2017. It has been widely communicated that the NHS pays approximately £200m into the apprenticeship levy each year and in 2018/19 there were just under 500,000 apprenticeship starts in health, public service, and care areas. The NHS has now reached 83 per cent of its public sector target.
To help address nursing shortages, employers are exploring and investing in all available options to support increased supply, including the scale up of nursing associate and nurse degree apprenticeships. These apprenticeships provide opportunities to build nursing supply through a ‘grow your own’ approach, which also supports social mobility and widening participation into degree-level professions.
Employers in the NHS face a unique challenge with the nursing degree apprenticeship, which requires a large ‘off-the-job’ element of up to 60 per cent as legislated by the Nursing and Midwifery Council (NMC), and the cost to backfill this must be met by the employer. This is a huge financial disincentive, requiring £150,000 investment from the trust for each apprentice. This significant investment required for each nursing apprenticeship is limiting the service’s ability to make full use of nurse degree apprenticeships. Health Education England and NHS Employers have worked together for two years to lobby government on behalf of employers to gain flexibilities in apprenticeship policy, with little success.
The recent government announcement to introduce a new payment of £2,000 to employers in England for each new apprentice they hire aged under 25, and a £1,500 payment for each new apprentice they hire aged 25 and over, from 1 August 2020 to 31 January 2021, will be very much welcomed by employers. It will further strengthen their apprenticeship offer, but further investment would also be welcomed to support the backfill of clinical placements for nursing, as the cost of this far exceeds this newly introduced incentive.
As a solution to this challenge, employers are asking for the ability to use the apprenticeship levy to support the backfill costs where the off-the-job element exceeds the 20 per cent that is required of a standard apprenticeship. Alternatively, funding could be provided through the new National Skills Fund, which focuses on a ‘right to retrain’ and proposes to include funding for further strategic investment in skills and apprenticeships. Providing this funding would significantly strengthen the nurse degree apprenticeship offer, support government with the commitment of 50,000 more nurses, and provide anchor institutions like the NHS to be part of the solution to local and national economic recovery, in the aftermath of the COVID-19 pandemic.
Capacity to support and supervise large numbers of learners is another of the issues frequently raised by employers in the NHS. Many apprentices need a significant level of support, including pastoral support. The apprenticeships report from the National Audit Office shows a predicted deficit in the levy fund over the next three years, and the NHS is expected to significantly underspend on its levy.Therefore, we would ask that employers are able to use unspent apprenticeship levy funds to support infrastructure costs, as this will enable them to develop nurses through the apprenticeship route.
NHS organisations have made progress in the implementation of the nursing associate role. Health Education England paid for the education of the first 5,000 nursing associates to be trained, to encourage uptake of the role. In January 2020, the NMC announced that 1,560 people are now registered as qualified nursing associates one year after this new professional role joined the health and care workforce in England. This includes any nursing associates joining the register from overseas. The role has already proved to be popular with employers and individuals, as in June 2019 it was reported that more than 7,000 students had begun training since the role was introduced in January 2017. The numbers for training continue to expand. Employers in England recognise the value of this addition to the nursing family, as it bridges the gap between healthcare support workers and registered nurses, to deliver hands-on, person-centred care in a range of settings. It has provided employers with the opportunity to attract new talent into the NHS, and also to develop and retain significant numbers of staff already in support worker roles, making it easier to climb the ladder for those who want to become registered nurses.
Mental health and learning disability nursing
Although the numbers of nurses in England overall has increased, the number of learning disability (LD) nurses employed in hospital or community settings has reduced by 38 per cent from September 2010 to September 2019.
Significant, focused investment in the recruitment of LD and mental health nurses would be welcome. Most LD nurses come through a traditional university route. Employers have told us that there has been a reduction in the number of universities that offer a learning disability course, as sign up is often not high enough to make the course financially viable to run.
Mental health nursing has seen success in encouraging course sign up as the fill rate of trainee places has risen to 95 per cent in England, compared to 67 per cent in 2017. The Conservative Manifesto reintroduced an £8,000 bursary for living costs for mental health nurse trainees.
A major reason for the long-term decline in applications in LD courses is seen to be the reputation of the sector, which was compounded by the removal of the bursary. Many LD nurses are older, as are mental health nurses, and retrain as a second or third career to join the profession. A financial incentive to train as an LD nurse would be welcome as a short-term initiative while a longer-term mechanism to increase the flow of LD nurses is worked on.
Employers have had success in retaining their LD nurses by offering access to training and development. Trusts offer a variety of different options to staff, such as access to leadership and quality improvement courses, further education, and job rotations. Employers have suggested that the creation of a strong academic infrastructure in LD nursing would help to create more varied job roles, as it does in other areas of the nursing workforce. HEE has also committed to embedding peer support workers in mental health settings. This has the potential to become a valuable pipeline into mental health nursing. 
Staff health and wellbeing
Prior to the pandemic, employers have undertaken much work to ensure the health and wellbeing of their workforce. This was recognised in the 2019 NHS Staff Survey, in which 29.3 per cent of staff reported positive action on health and wellbeing by their employer (up from 28.6 per cent in 2018). However, 40.3 per cent of staff reported feeling unwell as a result of work-related stress, up by 0.5 per cent since 2018. More clearly needs to be done, and employers have extended their offer to staff during the pandemic.
Arm’s-length bodies and employers recognise the impact that COVID-19 will have on frontline staff, including nurses. A wide range of help and support, including essential health and care support, help with food shopping, or social and emotional support, is being provided by NHS organisations locally. Specific guidance has been developed for healthcare professionals, and workforce and HR leaders are utilising these resources to fully support the wellbeing of their staff. This includes providing nurses with holidays and rest periods during the pandemic, support with their mental and physical health, and providing flexibilities to those with caring responsibilities. Employers recognise that this support needs to continue in the longer term to ensure that nurses and other staff groups do not suffer from burnout.
Huge efforts have been undertaken by employers across the NHS to retain the nursing workforce over the past five years, and measures to improve retention of staff have seen tangible benefits.
In 2016, NHS Employers worked with 92 NHS trusts to support them to develop retention strategies. Building on the success of this programme, NHS Improvement and NHS Employers further supported employers with staff retention, providing hands-on support and practical resources, as well as targeted interventions such as flexible working, to retain the nursing workforce. This resulted in national nursing staff turnover rates falling from 12.5 per cent at the start of the programme, to 11.9 per cent in the summer of 2019. This collaborative effort and progress to date has been achieved through good working relationships across national organisations and between national and local organisations.
In addition to this, in 2019, continuing professional development (CPD) funding was restored. As part of the boost, nurses have access to a personal training budget of more than £1,000 over three years to undertake the 35 hours of CPD needed to revalidate. This investment has been welcomed by employers in the NHS, and is vital to support training capacity, service quality, financial wellbeing and recruitment and retention of nurses.
Prior to the Agenda for Change contract refresh in 2018, the NHS had been subject to a lengthy public sector pay freeze, which hampered both attractiveness to train in the NHS and the retention of staff.
However, reported satisfaction with pay levels is now much higher for nurses and other non-medical staff as a result of the significant investment made by the government from 2018 to 2021. We are now in the final year of the agreement reached with the non-medical trade unions, and there will be a need to reach another longer-term position in relation to reward, particularly given the response of NHS workers to the pandemic. If additional investment is made in rates of pay, as trade unions have requested, then HMT must provide additional resource to NHS organisations.
Starting salaries have been raised to support attraction and pay progression has been accelerated to support retention.
Increases in starting salaries
Cumulative change from current (2017/18) starting salaries:
Cumulative change from 17/18 (£)
Cumulative change from 17/18 (%)
Earlier this year, emergency legislation was passed to enable second- and third-year undergraduate students, and postgraduate students to undertake extended paid placements to support the NHS COVID-19 response. 26,762 student nurses and student midwives opted to take paid placements. Arm’s-length bodies are now supporting student nurses and midwives to transition back to supernumerary clinical placements, so that they can complete their studies and be ready to join the NMC register in due course. Employers are also beginning conversations around the employment options available to students to become part of the nursing workforce following course completion.
While regulations were changed quickly to be able to use students and those not on register anymore, we will return to normal education practice. Employers are prioritising this to ensure that year 3 students complete on time, and that year 1 and year 2 students who are behind on placement hours are supported to catch up. Some employers may need bespoke support to ensure this transition runs smoothly and does not cause delays to the pipeline. We cannot underestimate the challenge of catch up for people already on programme; expanding numbers and trying to do this whilst managing COVID-19; bringing other services back on stream; the potential for a second surge, and winter pressures. This will need a huge collective effort and carries with it several risks.
There is a concern that nursing programmes requiring NHS experience or work experience may be at risk of creating barriers to people, or reducing their numbers, as people have not been able to get work experience during the COVID-19 outbreak. Employers continue to inform us that it will be 2021 at the earliest before work experience and pre-employment programmes offering hands-on experience will resume. Therefore, it is proposed that work is undertaken at a national and local level to support employers, further education and higher education institutes to flex this entry requirement to nursing courses until the NHS is able to offer work experience again. To counteract this, the NHS is working with education institutions to look at ensuring all potential avenues are considered for clinical placements, including primary care, social care, private organisations and the third sector.
We have also heard concerns that are being explored around the impact of COVID-19 on recruitment, with a worry that the population may be less keen to take up vacancies in the sector due to risks of contracting the virus and the impact the virus has unfortunately had on some ethnic minority staff groups. Further research should be undertaken to understand the depth of this challenge and explore ways to mitigate it.
Many apprenticeships have been paused during the pandemic, with many apprentices being redeployed to work on the frontline. National conversations between Health Education England, the Department for Health and Social Care, NHS Employers, the Department for Education and the Institute for Apprenticeships and Technical Education resulted in flexibilities as to how the end-point assessment could be delivered for apprenticeships including healthcare assistants, nursing associates and nurse degree apprenticeships. This has been invaluable, as it ensures that pipelines from the healthcare assistant and nursing associate apprenticeships can progress as planned onto nurse degree apprenticeships.
That said, while many employers have kept apprenticeship programmes running during COVID-19, some employers have not been able to and as a result, existing apprenticeship programmes have been paused or delayed, and new programmes are not being started as planned. Employers have informed us that they will reach a point where levy funds start to expire as they have paused/delayed starts to apprenticeship programmes during this time. For this reason, employers have asked for an extension of 12 months to the time that levy funds are available in digital accounts, in addition to the existing 24 months in which to spend levy funds, to ensure that, post COVID-19, employers can use this route to train NHS nurses.
It will take time to recover from the pandemic, and we need patience and understanding from politicians, as well as realistic expectations on what the NHS can deliver. Understanding the strain of COVID-19 on health and care staff and the cumulative effects of restoring services, significant vacancy rates and a possible second peak will be critical. Focus and resources should continue as we look ahead to provide ongoing support to employers in health and social care to strengthen their nursing workforce.
We would ask that government supports the NHS in the short term by:
We would also ask that government supports the NHS in the longer term through:
Addressing the nursing shortfall would not only be beneficial to the NHS, it would also allow anchor institutions like the NHS (usually the largest employer in a community) to be part of the solution to local and national economic recovery post-COVID-19; to address skills gaps; generate future supply pipelines and provide opportunities within communities that may not have considered the NHS as a career option. It we can continue to work together we can go further to address the challenges that employers face with nursing supply and diversify nursing at all levels of the profession.
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