Recent history of nurses' pay

  Since 1984, nurses' pay has been determined by an independent Pay Review Body. Every year the Review Body considers evidence from the health departments, employers, and staff organisations, then makes an independent recommendation to Government.

  In 1995 and 1996 the Review Body recommended mixed national and local pay awards. This outraged nurses and precipitated a heated campaign led by the RCN. In 1997 the costly experiment in local pay was ended when the Review Body recommended a 3.3 per cent national award, although the value was reduced by the Government's decision to stage the award.

  In 1998 the Review Body recommended a 3.8 per cent national award for nurses, which was again staged by Government. As a result, nurses have had to cope with below the rate of inflation pay awards for the last four years.

  Nurses are a highly committed and highly motivated workforce. They face increased workloads, and growing staff shortages. They feel patient care is being compromised. Combined with inadequate levels of pay and poor opportunities for career progression, these pressures mean that low morale among nurses is inevitable. If the NHS is to solve the nursing shortage, and recruit and retain nurses of the calibre required to deliver the Government's vision of a revitalised, modern and dependable NHS, nurses must begin to feel valued.

  Pay is part of the problem, so pay must be part of the solution. When nurses are asked to indicate the single most important factor which would reduce their likelihood of leaving the NHS, better pay tops the list. A fair pay increase cannot provide the complete answer to the problem of nurse shortages, but it can go a long way to stemming the flow of nurses from the profession by showing how much they are valued.

  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.

Nurse pay compared with other professions

  There is a range of public service occupations with which nurses can be compared, both in terms of their level of job responsibility and because they draw from similar labour markets and demand broadly equivalent educational attainment.

  These groups also tend to have career paths which lead to higher earnings than those of nursing staff. This needs to be taken into account when making comparisons. The starting pay of registered nursing staff is between 12 per cent and 20 per cent less than comparable professions.

  According to the most recent IDS survey of graduates6, which relates to 1997 salaries, three years after entry, a typical 1994 graduate would earn £22,699 a year (£22,454 in the public sector) compared to £12,350 for a nurse who had stayed on the "entry" Grade D (1997 scales). A nurse who had progressed to the midpoint of Grade E would still only earn £15,150. By contrast the pay of a police constable would have risen in the same period from £15,438 to £18,783. The average teacher's pay would have risen from £15,012 to £16,689.

  And nurses' career opportunities are actually becoming more restricted. Higher grade posts are disappearing, limiting prospects for progression. Recent research1 shows that of nurse who first registered in 1989, nearly 80 per cent had moved beyond Grade D by their fifth year of practice. By contrast, only 55 per cent who first registered in 1993 had gained promotion. Such changes in the grade mix have a knock-on effect on second-level nurses whose prospects are even more limited.

Nurses' morale

  The Pay Review Body commented in its 1997 report that while motivation and commitment remained high, morale amongst nursing staff was often low. In 1998 the Review Body commented further [par. 43]8:

  ". . . the evidence we have received, and the visits we have made, suggest to us that this remains the position. The reasons for low morale vary but continue to include heavy workloads, made worse in some instances by staff shortages. On our visits staff referred to being unable to finish their shifts on time and working overtime, some of which was unpaid, and it is clear to us that on occasions Trusts have adopted the policy of leaving certain vacancies unfilled in order to manage their budgets. Complaints were made as well by nurses about the size and nature of training budgets. Funds for development training were felt to be especially constrained. Reference was also made to the culture of nurses having to use some of their own time to undertake training and often having to pay for at least an element of the training themselves: this was not felt to be the same in comparable professions. Another common complaint was that of a lack of opportunity for salary and career progression caused both by higher posts disappearing and by the nature of the clinical grading structure itself. This complaint appeared to be compounded by the fact that nurses in all grades . . . appeared to be taking on a wider range of duties than ever before, including some formerly undertaken by junior doctors."

  Nurses are highly motivated. This is demonstrated by their willingness to work long hours, often with no additional remuneration. Increased incidence of overtime and "excess hours" not only indicate increased workloads, they are also an indicator of the extent to which staffing levels, and the availability of staff, are inadequate to cope with demand for services. However, NHS employers should not assume that the current nurses' goodwill is infinite, and should look to long term solutions to staff shortages.

 IV. WORKFORCE PLANNING, THE METHODS USED AND THEIR QUALITY

Estimating the nursing workforce

  Nurses are the largest single group of staff working in health care. In the NHS, 80 per cent of direct patient care is delivered by nurses, accounting for a third of revenue expenditure and almost half the total salary bill. Research shows that investing in a high proportion of registered nurses delivers better patient care and is cost effective.

  There are over 637,000 nurses and midwives registered with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC)3—nursing's regulatory body. This is the pool from which the NHS and other employers recruit staff.

  Approximately three-fifths of registered nurses work within the NHS. The number of registered nurses in the NHS has remained comparatively unchanged since the late 1980s. In 1998 the NHS in England employed 248,070 whole time equivalent staff (wte)9.

  The number of nurses working outside the NHS has increased markedly. Independent hospitals, clinics and nursing homes in England employed 32,430 wte nurses in 1990, and 51,230 in 1997—an increase of 58 per cent10. In addition, there are estimated to be up to 8,000 occupational health nurses in the UK, 80 per cent of whom work in private sector businesses. The number of nurses working alongside doctors in general practice is also increasing rapidly. In England there were 10,080 practice nurses (wte) in 1997, compared with 7,740 (wte) in 19909.

  Although there appear to be more nurses working, many of these nurses are not working full-time. 33 per cent of NHS nurses now work part-time, as do 84 per cent of practice nurses and 34 per cent of those working in the independent sector5. Gender is the reason many nurses seek part-time employment, due largely to child care and other family care commitments. Ninety one per cent of registered nurses are women.

A brief history of workforce planning

  Robust workforce plans are critical to minimising possible labour shortages or an over supply of newly qualified staff, both of which have cost implications to the service. Yet before the late 1980s, workforce planning for nurses and other professional staff was rarely undertaken in the NHS. Regional health authorities produced strategic plans that attempted to plan up to 10 years ahead, but these plans were little better than a series of guesses and "wish lists". They also had little impact on the size of education and training intakes as these were dependent on the size of education budgets held at district level. Local schools of nursing were managed by districts which in those days were also responsible for the local acute and community health care providers.

  Project 2000 was designed to ensure that nurses' skills and knowledge could meet the changing health needs of the population, such as the stronger emphasis on community care. When Project 2000 was implemented, higher education providers took over nurse education, resulting in the concentration of education into fewer centres. Regional health authorities took over responsibility for commissioning education intakes. For the first time, the scale of the education and training budgets became visible to general managers. The sums involved are large (£800 million) and NHS Trusts, who see themselves as the indirect funder of education, and the eventual employers for most health care professionals clearly have an interest in ensuring that the money is spent in such a way that the health service benefits. As regional health authorities were to be slimmed down as far as possible to give trusts much more independence, education consortia were created so that they could take over the responsibility for education and training.

  Many consortia began to carry out workforce planning in earnest in 1995. The results were very mixed. Usually, junior workforce planners in trusts had difficulty piecing together the information before the consortia had to decide on how many places to commission from education and training providers. There were cases of double counting as several trusts all thought they were going to expand at the expense of their neighbours and increased their demand for staff accordingly, when in reality there was less money year on year for the acute sector. The more likely scenario was in fact downsizing and possible closures or mergers, but this did not necessarily reduce demand for registered nurses. Over-estimation of supply also occurred because many consortia took insufficient account of the demand for nurses from the private and independent sector, which accounts for a quarter of nurse employment.