SUMMARY OF RECOMMENDATIONS

The current shortage of nurses

  The Government's vision of a modernised and revitalised NHS depends on the contribution of nurses and nursing. Issues of low morale, low status and low pay mean that there aren't enough nurses to fulfil current needs, let alone the Government's vision. The NHS is in the grip of a crisis: it faces the worst shortage of nurses in a quarter of a century.

  Recommendation: The Comprehensive Spending Review announcement for Health has provision within it for resolving the nurse recruitment and retention problems discussed in this evidence. It would be paradoxical of the Government to invest billions in infrastructure projects and modernisation programmes if at the same time it refused to invest in the nursing workforce.

The new NHS must be a modern employer

  Unless the NHS becomes a more modern employer, nurses will not stay in the profession or be attracted to it. Working Together, the human resource strategy for the NHS in England, announced steps to improve staff training and development, to challenge discrimination and to introduce flexible ways of working so that nurses can combine work with family life. If these steps are taken, the NHS will become a more modern and attractive employer.

  Recommendation: It is crucial that the Government measures progress—we can't miss this chance to turn good intentions into reality. A tough approach to ensuring that trust managers implement measurable change is essential. The RCN welcomes the Government's policy of setting targets to record and monitor workplace accidents and violence to staff, to ensure policies are in place to tackle harassment, and to demonstrate that trusts are getting better at keeping NHS staff.

Workforce planning—what kinds of nurses will we need in the new NHS

  The establishment of National Service Frameworks in the Government's quality paper A First Class Service throws into sharp relief the issues of skill and staff shortages and the implications this has for the NHS.

  Recommendation: Work needs to be undertaken to address the staffing and skills problems if the plans for National Service Frameworks are to deliver a truly national service.

Nurses' pay and status

  Nurses' pay is low compared to that of other groups who draw from similar labour markets and require similar educational attainment. Moreover, in recent years nurses have had to fight to achieve even meagre pay increases. Equal pay for work of equal value is central to the successful reform of NHS pay structures. Nurses are substantially underpaid compared with staff in a number of male-dominated professions, such as medicine, clinical psychology, pharmacy, who earn £10,000 more than a nurse doing work of equal value. Another striking example is the comparison between white collar managers (such as NHS trust finance directors) and nursing directors.

  Recommendation: The RCN believes the single most effective way of improving the image and status of nursing, and reducing the nursing shortage, is to show that nurses are valued by increasing their pay.

Workforce planning

  The RCN believes that the current emphasis on local workforce planning is a step in the right direction, but needs to be modified in the following ways:

—  There must be greater and more open dialogue between the education consortia (who purchase education) and the universities (who provide it). In many cases relationships are still at an immature stage. Employers have only limited understanding of some cultural aspects of higher education, while universities do not always recognise employers legitimate concerns. It is also vital that employers, mainly NHS trusts, communicate their predicted staffing needs to education providers.

—  Accurate workforce planning must take full account of the competition for nurses from the independent sector.

—  While many of the key decision makers on education consortia are from a nursing background, there is no explicit recognition that nurses and other professionals are key to the process of planning the healthcare workforce. The RCN believes that nursing must be represented on all consortia.

—  Local planning must be tempered by a UK-wide overview of supply and demand. Many nurses move across regions, and across country borders upon qualification or at some other point in their career. While there are some minimal checks and balances within England there is no UK wide perspective.

—  The RCN began to predict the current shortage of registered nurses in the early 1990s, but was met with blank stares and denials by the Department of Health and employers' organisations. Workforce planning decisions at local, country and UK level, and the data which underpin these, should be available for public scrutiny regularly and as a matter of course.

Continuing Professional Development

  A highly-skilled nursing workforce understands inherently that professional education—Continuing Professional Development (CPD)—is essential throughout one's career since clinical care is continually evolving to improve the quality of patient care. Access to CPD is a prerequisite for all health professionals and should be available on an equitable basis. Currently this is not the case. Nurses frequently have to fund their own CPD activity and participate in their free time. A 1997 Institute of Employment Studies survey of how nurses meet their Post Registration and Practice (PREP) requirements indicated that only 35 per cent of NHS staff were allowed time off work for private study and only 32 per cent received financial support for study.

  Recommendation: The lack of a national financial framework to underpin CPD for nurses is a major barrier to quality improvement throughout the NHS.

 MEMORANDUM

  The Royal College of Nursing (RCN) welcomes the opportunity to submit evidence to the House of Commons Health Select Committee's Inquiry into Future NHS Staffing. This issue is of increasing concern to health care professionals and the public and has direct influence on the care received by patients.

  The Royal College of Nursing (RCN) is one of the world's largest professional organisation of nurses with over 310,000 members who are registered nurses and midwives working in hospital and community NHS trusts, general practices, higher education and the independent sector and nursing students. The RCN has a UK-wide network of branches and national membership forums representing over 100 specialist nursing interests including critical care, day surgery, cancer nursing, community nurses, care of the elderly, mental health.

I. FUTURE STAFFING REQUIREMENTS OF THE NHS

  The Health Select Committee should review future staffing requirements in the context of proposed reforms to health and social services, as well as with a clear understanding of current nurse shortages and the current NHS workplace environment.

The Scope of the NHS reforms

  The Government's policy on health has changed dramatically since the election. These new policies, and in particular the white2 and green papers2 on the future of the NHS, set a challenge for our health care systems. They emphasise high standards in quality of patient care, and measurable improvements in performance through the Commission in Health Improvement, the National Framework for Assessing Performance and the Annual Survey of Patient and User Experience in the NHS.

  The RCN welcomes the focus on patient care and the change in philosophy to improve health rather than provide a national sickness service. The Government has sought to shift decision making and services from secondary to primary health care. Primary Care Groups in England are to be the commissioners of local health services and even some secondary health services. This will lead to very different arrangements for community-based health services and will increase the demand for nurses in all areas.

  It is possible, when the plans for reforming social services are published later this year, that the demand for nurses will increase still further. In reviewing future staffing requirements, therefore, the Committee needs to take into account the full implications of the Government's reform agenda.

Nurses are critical to fulfilling the NHS reforms

  Currently 80 per cent of patient care is provided by nurses. Nurses are pivotal in meeting the Government's challenge: they are key to the planning and provision of services in trusts and in local commissioning bodies; they are vital to the development of clinical governance; they are the backbone of NHS Direct telephone consultation; they are needed to staff wards and theatres so that waiting list targets can be met. They are essential in meeting the health improvement plans and for fulfilling the aims of the Health Action Zones.

  Nurses constitute an expert, innovative and flexible workforce who bridge the gap between secondary and primary health care, institution and community care, hospital and home.

Current nurse shortages

  Issues of low morale, low status and low pay mean that there aren't enough nurses to take on the Government's challenge. The NHS is in the grip of a crisis: it faces the worst shortage of nurses in a quarter of a century. But the Government's vision of a modernised and revitalised NHS depends on the contribution of nurses. Without a well resourced, confident and highly motivated nursing workforce, the Government's vision for the health service will not be achieved.

  The number of registered nurses is shrinking and the number of new nurses registering to practice has declined to its lowest ever level. Current shortages can only worsen unless action is taken to retain those working in the NHS, to persuade part-time staff to increase their level of participation, and to encourage some of those currently outside nursing to practice. At the same time, there has been a decline in the number of nursing students. New entries to the nursing register were the lowest ever at 11,208 in 1996-97, down from 13,931 in 1992-933.

Shortages

Facts and figures:

  The figure reported by the Pay Review body of 8,000 nursing vacancies is an absolute minimum. The Evening Standard, 30 September 1998, reported that trusts in and around London were operating with a deficit of 4,800 nurses;

  Large decline in the numbers on the nursing register because of:

—  retirement—a quarter of registered nurses will be eligible for retirement in the year 2000;

—  nurses not keeping up their registration;

—  low numbers of newly qualified nursing registrants—for the first time ever, in 1996-97 there was a shortfall in applications for nurse education places, with just 15,400 applications for 16,100 places (95 per cent application rate). In 1993-94 there were 18,200 applications for 12,000 places (150 per cent application rate)4.

  One in six nurses registering to work for the first time is from overseas.

  Nursing is an ageing population; in 1992, 30 per cent of respondents to the IES survey5 were aged under 30 compared to just 16 per cent in 1998; the average age of NHS nurses is 38.

  The pool of registered nurses who are not working is between 77,500 and 85,300. This pool is far smaller than estimates made by the Department of Health.

  NHS Confederation evidence to the Pay Review Body shows of 110 organisations which responded to their survey:

—  78 per cent reported medium/high recruitment difficulties for nurses and midwives; recruitment of staff nurses, the nurses at the heart of the hospital service, is particularly difficult

—  58 per cent of employers report medium/high levels of difficulty in recruiting and keeping D grade nurses

—  57 per cent report medium/high levels of difficulty in recruiting and keeping E grade nurses

—  specialist areas are also hard hit

—  32 per cent reported high levels of difficulty in intensive care

—  29 per cent in care of older people

—  28 per cent in theatres—a specialism key to tackling the Government's waiting list initiative

  Recommendation: The Comprehensive Spending Review announcement for Health has provision within it for resolving the nurse recruitment and retention problems discussed in this evidence. It would be paradoxical of the Government to invest billions in infrastructure projects and modernisation programmes if at the same time it refused to invest in the nursing workforce.

The new NHS must be a modern employer

  At a time of severe nurse shortages, we are particularly pleased to see that trusts will be expected to show that they are better able to keep their nurses. Unless the NHS becomes a more modern employer, nurses will not stay in the profession or be attracted to it. The recently announced steps to improve staff training and development, to challenge discrimination and to introduce flexible ways of working so that nurses can combine work with family life, will make the NHS a more attractive employer.

  All nurses should be able to work safely and without fear and we look forward to employers taking real action to tackle violence. The RCN has recently launched its own Working Well Initiative to encourage nurses and their employers to improve workplace safety and occupational health in general. Our publicity and information materials are available for the Committee's review.

  The RCN recognises that the launch of Working Together, the human resources strategy for the NHS in England, is an ideal opportunity to make the NHS a modern employer—good news for NHS staff and patients alike. A confident and motivated workforce, with staff involved in planning how health care is provided, is best placed to give quality patient care.

  Recommendation: It is crucial that the Government measures progress—we can't miss this chance to turn good intentions into reality. A tough approach to ensuring that trust managers implement measurable change is essential. The RCN welcomes the Government's policy of setting targets to record and monitor workplace accidents and violence to staff, to ensure policies are in place to tackle harassment, and to demonstrate that trusts are getting better at keeping NHS staff.

Family Friendly Policies

  Family friendly working practices are those which allow nurses to combine working with family responsibilities. They include help with child care, special leave (such as maternity leave, career breaks or carers' leave), flexible working arrangements such as job sharing, part-time work or term-time work.

  Caring responsibilities: over 60 per cent of nurses have caring responsibilities but only a third of those nurses reported that cre"che or nursery places were available to them at work5.

  One vital area side-stepped in the strategy is nurses' pay (see below). Poor pay and poor career prospects are key elements in prolonging nurse shortages, and a decent pay award to nurses must form a major part of the solution.

II. WORKFORCE PLANNING—WHAT KINDS OF NURSES WILL WE NEED IN THE NEW NHS

  The Government's impetus towards increased hospital throughput, decreased surgery waiting lists, day surgery initiatives, early discharge and the delivery of complex, "high tech" care to individuals of all ages in their own homes and communities all require the skills and knowledge of expert nurses.

  In particular, changes in mental health care cannot be implemented without a skilled and qualified nursing workforce who are able to work across the boundaries of institutional and community care. In-Patient Mental Health Services in Inner London, a snapshot survey of acute psychiatric wards published by the RCN and the Institute of Psychiatry showed that, on one particular day during July 1997, one in four acute psychiatric wards was unable to admit severely disturbed patients due to staff shortages, even though they had made extra beds available.

  High quality discharge planning for patients leaving hospital and skilled assessment of older people for community care relies heavily upon the expertise of registered nursing staff.

  The announcement of the establishment of National Service Frameworks in the Government's quality paper A First Class Service (England) has thrown into sharp relief some of the issues of skill and staff shortages and the implications this has for the NHS.

  For example, the RCN has found that work looking at progress relating to cancer and mental health has highlighted staffing and skill concerns that need addressing if National Service Frameworks are to be a success. Also, a financial vision is needed to ensure that a uniformly high standard is achieved. With regard to mental health we have found that the absence of a clear financial vision for the delivery of high quality patient care may continue to produce the "unacceptable variations" in patient care that the National Service Framework seeks to remove.

  The Calman-Hine Report, referred to in A First Class Service, does provide an excellent blueprint for a new approach to the development of a national framework for cancer services. However, even following the launch of the Calman-Hine Report, there is no evidence of the evolution of a first class service. There are great variations in the implementation within eight different English regions. The failure to review how this Report has been implemented, and pick up shortfalls, continues to perpetuate a "postcode lottery" for cancer patients.

  One key problem is a shortage of nursing staff and skills (see below). At best it could be said that Calman-Hine has prompted change, much good work has, and is, being undertaken in many places, but the quality of services will need great attention if they are to move away from a patchy delivery.

  Recommendation: Research must be undertaken to address the staffing and skills problems highlighted by the plans for National Service Frameworks, if these are to deliver a truly national service.

Skill shortages

  A First Class Service refers to the Calman-Hine initiative as an example of a national service framework; the impact of this excellent Report has not been assessed. To date, the challenge of setting in place programmes for workforce planning/education and training for nursing (a discipline providing one of the corner stones for the implementation of the Report) has not been addressed. For example, Nursing Times2 September 1998, reported that a shortage of suitably trained nurses is slowing down implementation of the Calman-Hine recommendations, delaying improvements in services.

  A report on the workforce planning implications of Calman-Hine for health care professionals in the Northern and Yorkshire region found that only 64 nurses out of 18,000 in 24 health service organisations held the professionally accredited ENB 237 (Adult oncology) qualification in cancer care.

  The solution to this shortage, to commission multi-disciplinary, professionally-accredited oncology courses at degree and diploma level, is nowhere close to being put in place on a national basis. In the North West a regional study showed a shortage of places on courses, suggesting a total of 600 students for every available place on a course for post registration cancer qualifications.

Community Children's Nurses

  Another nurse shortage example was highlighted in the Health Select Committee's own inquiry into services for children and young people. The Committee's Report recognised the value of community children's nurses who help families cope with severely sick or dying children. These children may have conditions such as cystic fibrosis, severe forms of cerebral palsy, or cancer. Some of these children need assistance with breathing, for example, requiring continuous oxygen or the assistance of a ventilator. Many need assistance with feeding through a tube into their stomach or directly into their veins.

  Along with the technical skills needed to assist children to breathe, feed and receive a range of drugs and treatments, community children's nurses have to be excellent networkers. The health and social care service are enormously complex; very often parents know what care they need for their children, but do not know how to go about getting it. They need help and advice from nurses who can access the system for them and deal with any barriers. This help includes negotiating with social services, voluntary organisations, the child's school and the local education authority, obtaining equipment, respite care and co-ordinating services for the child and family. In 1998 only 50 per cent of the country had a community children's nursing service, of which only 10 per cent provided a 24-hour, seven day a week service.

The role of nurses on primary care groups

  The Government has announced the establishment of primary care groups (PCGs) in England in its White Paper, The New NHS: Modern and Dependable. Each PCG commissioning body will include two nurses. Nurses will thus be involved as never before at both strategic and operational levels of planning and provision of health care services. Local commissioning arrangements will focus on meeting health care needs of local populations and communities. To meet these needs, commissioning bodies will require an in-depth knowledge of local services, local people, local networks and local problems: knowledge which is second nature to nurses. The Government's vision will not come into being, however, if educational resources, in terms of both time and money, are not made available to develop these nurses' contribution and that of other PCG members.

  Recommendation: A clear vision setting out the management and development programmes for PCG Commissioning Body members is needed, and the resources must be made available.

III.  NURSES' PAY AND STATUS: IMPLICATIONS FOR FUTURE NHS STAFFING

  Nurses' pay is low compared to that of other groups who draw from similar labour markets and require similar educational attainment. Moreover, in recent years nurses have had to fight to achieve even meagre pay increases. Equal pay for work of equal value is central to the successful reform of NHS pay structures. Nurses are substantially underpaid compared with staff in a number of male-dominated professions, such as medicine, clinical psychology, pharmacy, who earn £10,000 more than a nurse doing work of equal value. Another striking example is the comparison between white collar managers (such as NHS trust finance directors) and nursing directors.

  Registered nurses have not shared in the UK's economic growth in recent years. They see what people with similar levels of responsibility in other professions can earn and recognise how unfairly rewarded nurses are. They are tempted to leave the profession for jobs in which they feel their value is recognised. Potential nurses see the clear disparity between what they could earn, the career they could expect, the status they would have as a nurse, and the lifestyle they would enjoy in other occupations. Increasingly, they are choosing careers elsewhere.