1. careers
2. nursing

Registered Nursing
Home Association
John Hewitt House
Tunnel Lane
Kings Norton
Birmingham
B30 3JN
Nursing – A sector in crisis
Response by the Registered Nursing Home Association to the call for
evidence to a partial review of the Shortage Occupation Lists for the UK and
for Scotland.
Migration Advisory Committee
Frank Ursell
Chief Executive Officer
Registered Nursing Home Association
December 2014
Executive Summary
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Current Reports suggest that there are currently up to 20,000 vacant nursing
posts across the NHS
At this time there are 15,000 nurses expected to graduate this year, however
25,000 are expected to leave the NMC register so the number of UK nurses
would drop by 10,000 per year without any immigration.
Demand for nurses is expected to rise by 1% per year, or 6,000 nurses per
year.
In the NHS 14% of all current nurses are not British citizens and in a recent
study 45% of NHS trusts interviewed are actively recruiting abroad.
In Adult Social Care 38% of all nurses working in the sector are currently
recruited from abroad, in London and the South East this rises to 56% and
54% of nurses.
There are around 10,000 vacancies in Adult Social Care, and when these two
projections are added together, there is a likely shortage of cica 30,000
nurses
There are currently no plans in place to meet the deficit in nurse supply that
will quickly become insurmountable.
The Adult Social Care Sector has no control over the training and supply of
nurses and is dependent upon the Department of Health to do so on their
behalf
Introduction
There are currently over 500,000 nurses registered to work within the health and
social care system in the UK. The training programmes in place at this time have
suffered large cuts due to financial pressures placed on NHS trusts and the number
of new nursing student places commissioned in the UK by the Strategic Health
Authorities in 2012/13 was 11,400 and this will fall to 11,100 for the following year.1
This is not predicted to be sufficient to meet the growing needs of the health and
social care system in a society with a fast growing elderly population.2
The current system is propped up by a large number of immigrant workers from both
within the EU/EEA and beyond. Roughly 14% of all nurses working within the NHS
are not currently British nationals.3 Furthermore, a much larger number of people
working in the NHS have received British Citizenship having been resident in the UK
for many years, meaning that this figure will be a low estimate as many more will
have originally been born elsewhere in the world. A recent report that interviewed
100 NHS trusts showed that 45% of trusts interviewed are actively recruiting from
abroad to fill current posts and more are expecting to do so this next year.2 The
report also highlighted that 83 percent of the surveyed NHS trusts are experiencing
qualified nursing workforce supply shortages in the upcoming years with and
estimated 12,566 nursing posts currently vacant. 2
The Adult social care sector is one of the largest employers of nurses outside the
NHS and the increase in demand expected in nursing care over the next 10 years
has not been taken into account by any study carried out thus far. The adult social
care sector is estimated to employ 50,000 nurses and of these 38% of these are not
UK nationals with 31% being recruited from outside the EU/EEA. In some areas of
adult social care over 50% of nurses working within adult social care are employed
from outside the UK, with London and the South-East employing 56% and 54%,
respectively, of their nursing staff from overseas. 4 These figures are consistent with
the results of a recent survey of members undertaken by the Registered Nursing
Home Association.
A flurry of recent reports and articles published over the past year point towards a
healthcare system in crisis with up to 5% of all NHS nursing positions, c. 20,000 full
time positions, currently un-filled according to a recent RCN report.5 In addition, the
number of nursing homes in the UK is predicted to rise steeply over the upcoming
years, leading to a greater demand for and competition for the small pool of nurses
within the UK.
The unavoidable conclusions to be drawn from the current picture is that the need for
nurses is desperate and will continue to remain so. Although the use of foreign
nurses is more prevalent within the social care sector than the NHS, 38% compared
to 14% respectively, the dependency on an immigrant workforce is undeniable. This
reliance by the health and social care sector is likely to get worse with a 15%
reduction in the number of training places commissioned over the last 3 years
according to a recent response from the RCN.6 This paper will look in more detail
into the projected supply of nurses, and attempt to bring together an estimate of the
future demand in both health and social care and how this may be met.
RNHA Survey of Nurse Shortage November 2014
To inform this call for evidence, the Registered Nursing Home Association undertook
a survey of its members during November 2014 which asked them to report their
experience of shortages of Registered Nurses. Some 120 respondents out of a total
of approximately 1000 members gives a credible 12% response rate which allows
meaningful extrapolation of the findings.
Summary
Nursing Homes are finding it very difficult to recruit Registered Nurses even when
they recruit from outside the UK or outside the EU/EAA. Advertising is now seen as a
waste of money, since there are no applicants responding to those adverts.
Recruitment agencies are expensive, produce very low numbers of highly variable
candidates who leave the Homes as soon as they are registered with the NMC.
Existing Nursing Homes are reliant for 26% of their Registered Nurses on staff who
were trained outside the EU. Of these 5% entered the UK after April 2011 and hence
will not be entitled to ILR and need to leave the country at some point after April
2016.
Employee benefits are severely constrained in cases where Nursing Homes care for
people who are publicly funded.
This study reinforces the view that of the 45,000 Registered Nurses across the 4,000
Nursing Homes in England, there could be as many as 10,000 vacancies for such
staff.
The findings
The average Nursing Home surveyed employs 11.4 Registered Nurses when they
have no vacancies. Given that there are 4,000 Nursing Homes in England and that
RNHA members tend to operate the smaller Nursing Homes, it can be concluded
that there are currently more than 45,000 Registered Nurses working in those
Homes.
The average vacancy rate of the Nursing Homes responding to the survey was 2.56
vacancies per home. Extrapolated to all Nursing Homes this means there are
currently more than 10,000 vacancies for Registered Nurses in Nursing Homes in
England.
When analysing the place of training of those Registered Nurses, some 62% gained
their registration in the UK, 12% trained in the EU/EAA and 26% gained their
qualification outside the EU/EAA.
The salary offered was typically between £23,000pa and £30,000 pa, with only a
small proportion (less than 10%) attempting to recruit to a salary level below £23,000
pa and a similar percentage (7%) prepared to offer in excess of £30,000pa. The
average salary was just over £25,000pa based upon a 37.5 hour week.
Recent history of recruitment
The recruitment of Registered Nurses follows a very similar pattern for many of the
Nursing Homes completing the survey. Local and national advertising is producing
very few, and in many cases no applicants. Even when regular adverts are run on a
regular basis, advertising for RN's is now seen as not worth the effort.
The first line of action is then to ask existing RN's, as well as those in management
positions with a RN qualification, to pick up the shifts on a temporary basis. Whilst
this can address the issue in the short term it is not sustainable in the medium and
long term.
Recruitment agencies are then employed with very mixed results. Homes quote the
high fees associated with this activity as well as the highly variable quality of staff
who present for employment. Many instances are reported of staff being employed
for the minimum contracted period then leaving to work for either the NHS or
agencies.
Homes report that the use of agency staff is not just expensive (£30 per hour
appears to be common) but also results in the RN's not knowing the resident
population with the consequent reduction in the quality of care.
Recruitment by agencies from within the EU is then attempted with the common
problem of low levels of language skill, since there is no requirement for English
language skills when recruiting from the EU. Other issues raised are the different
cultures and values of qualified staff from some parts of the EU, eg Romania.
Following this is the progression to undertake the recruitment of nurses by the
organisations themselves, by directly registering with UKBA to be able to issue
certificates of sponsorship and taking part in an Overseas Nurse Programme with a
University. Even when this major commitment is undertaken Nursing Homes report
that as soon as the employees receive their registration with NMC the staff almost
immediately leave their employment and join the NHS for better terms and
conditions, either salary or pension.
Successful recruitment seems to only occur when staff who are friends of a friend or
known to colleagues is used to ensure that staff who start employment do so as a
positive step, knowing exactly what environment they are to work in and what hours
and rota patterns they are to work.
When asked when staff from outside the EU/EAA started work for Nursing Homes
out of the 26% of such staff filling RN positions some 21% have worked at those
Homes since before April 2011. This suggests that many overseas RN's have settled
here and are happy to remain employed by the Homes, since the majority will now
have Indefinite Leave to Remain. The remainder, some 5% of the total RN workforce
entered after April 2011 and therefore will never be eligible for ILR resulting in them
needing to be replaced at some point after April 2016.
Employee benefits
Homes were asked what additional employee benefits had been offered to attract
RN's. The most common factor was to increase pay rates and to emphasise the
flexible shift patterns which Nursing Homes can offer. However a number of homes
were unable to offer this due to increased resident numbers from LA's / CCG's where
weekly rates were not increased.
Paid meal breaks and handover times were quoted by many Nursing Homes as
changes to terms and conditions along with payment of registration fees and, for
overseas workers, help with finding accommodation or travel costs.
Pensions were mentioned for a significant number of Nursing Homes, where
pensions above the legal minimum were offered.
No attempt in this survey was taken of geographic differences across England but
different responses do suggest that some areas are completely unable to attract any
new staff.
Supply
It is important to recognise that the Adult Social Care sector has no control over the
supply of registered nurses. HEE has the budget and responsibility for training all
NHS staff. Their only obligation towards the Adult Social Care sector is to be mindful
of our need for nurses. There is little, if any, evidence that this is happening.
Almost all nursing placements at universities are funded by NHS trusts. This allows
decisions to be made on a local basis regarding upcoming demand for nurses.
However, with the recent financial pressures being faced by NHS trusts there has
been a significant reduction in the number of places commissioned. It is estimated
that over 10,000 fewer nurses have been trained over the last 3 years due to
underfunding from commissioners of nurse training. This is the only significant
internal supply of nurses to the UK health and social care sector. The Centre for
Workforce Intelligence [CfWI] estimates that a total of 17,400 student placements will
be commissioned in 2012/13 with 15% not completing their course. This leads to a
total of only 15,000 additional nurses being trained within the UK each year. 8 The
number of Adult nursing placements over recent years has been extremely low as
these courses have a lower percentage of students completing the course with less
than 9900 Adult nurses being trained in 2013/14. Information on the number of Adult
nurses trained is shown in the table below and highlights the recent reductions in the
training of new nurses:
Table taken from the workforce plan for England 2014/151
This supply of new nurses is set against a large number of nurses that are being
removed from the Nursing and Midwifery Council register. The CfWI, in their report
on the nursing workforce, have found two main reasons for de-registration of nurses;
Choosing to Retire [c. 13,000 nurses per annum] and other leavers, not due to
retirement of emigration [c. 12,000 nurses per annum]. 8 This means that it is
predicted that 25,000 nurses will be leaving the register each year. This leaves a
deficit in supply of 10,000 nurses per annum currently supplied within the UK.
The only other source of nurses for the UK are those trained abroad. Recent articles
have highlighted the desperation to recruit from abroad with 45% of all NHS trusts
asked in a recent survey stating that they actively recruited in EU and EEA countries
last year.2 The number of entrants through this route has risen over recent years to
over 3,400 nurses per annum to cope with this deficit.9 This is currently sustainable
due to the financial crises being suffered by many European countries and the
apparent security being offered by life in the UK. However, evidence from the WHO
suggests that there is a significant shortage of nurses in Europe 10 and as economies
recover this will become a less and less viable source of nurses.
An additional factor is the current Government’s rules on leave to remain [this is the
process in place for immigrants to become permanent UK citizens]. All nurses
coming into the UK after August 2011 must be earning over £35,000 per annum by
August 2016 to apply for leave to remain, otherwise they must leave the country.
This means that after August 2017 we will be losing a further c. 1,000 nurses per
annum as nurses that are unable to earn over £35,000 are sent home. Were
immigration to return to 2004/5 levels this figure could rise as high as 10,000 per
annum.9 Consequently there is a significant problem within the UK healthcare sector,
where the number of nurses currently training is significantly lower than the number
leaving the sector.
Demand
Demand is extremely hard to predict as it is dependent on a large number of factors.
However, in their recent report, the CfWI have attempted to accurately assess
demand in terms of number of nurses required. Whilst it is hard to accurately point at
a figure for demand, and all figures used in this section are informed estimates, the
unavoidable truth is that with an ageing population the number of chronic conditions
suffered by the British population is increasing. This will lead to a much higher
number of individuals that require support from both Health and Social Care.
The CfWI report on the nursing workforce suggests that there will be a need for an
additional 17,000 nurses in the UK by the year 2016. The report also includes a
worst-case scenario and this suggests that the increase in demand may mean that
we need an additional 98,000 nurses by 2016. This increase in the number of nurses
required is based on two main factors. The increase in the elderly population will put
more pressure on the health and social care system as more elderly become ill. In
addition the population of the UK is rising, leading to a greater stress across all
health and social care areas.
These numbers may be lowered by improvements in practice. However assuming no
drastic changes to existing practices and methods of work are made within the next
6 years, there will be an increase in demand for nurses by approximately 1% per
annum.8 The graph below shows the expected gap that will grow between the
number of nurses provided from UK training centres, the number of nurses supplied
if current immigration levels continue and the expected demand for their services.
Number of Nurses on the NMC register 2014 - 2020
680000
660000
640000
620000
600000
580000
560000
540000
520000
2014
2015
2016
No. of Nurses, No immigration
2017
2018
2019
2020
No. of Nurses, Current levels of immigration
No. of Nurses required
Data for this graph taken from the CfWI report on numbers of nurses leaving the
register vs. expected training commissions. 8 Data for immigration levels averaged
from the last 5 years immigration statistics reported to government. 9 Data for
demand is taken from the CfWI report and extrapolated to 2020. The starting point of
this graph assumes that demand is currently being met.
As the population ages there will be an ever increasing need for residential care
across the UK. Liang and Buisson have produced an Age Standardised Model to
predict the number of extra residential care beds required within the UK over the
next 10 years. Currently 45% of all residential care beds are provided in nursing
homes and this is unlikely to change moving into the future. Using this figure, we can
estimate the number of nursing home beds required by 2020 is almost 45,000 beds.
Currently the NMDS data shows that there are 40,000 nurses in the care home
sector, equivalent to 1 nurse for every 5 beds. This means that the nursing home
sector alone will require an additional 9,000 nurses by 2020, or 1,500 nurses per
annum.11
A plaster, but not a cure
Against this background the individual nursing home provider has to continue to
maintain a sufficient supply of suitably qualified staff in order to meet the current
Regulations. A number of other factors present themselves ;
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Agency nurses used to fill vacancies are charged at circa £33 per hour in
some areas. Where we are short of a nurse on a shift we have no alternative
but to meet these charges
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Nurses are, naturally, keen to work for agencies for higher salaries, thus
continuing the vicious circle by allowing them to cherry pick the shifts they will
work.
By the very nature of their inconsistent work for home owners, the nurse
agency workers lack knowledge of the patients in the nursing home and
provide poor service, thereby doing nothing for quality of applied care
Quality and safety of care is a significant issue when related to the lack of
adequate nurses to employ, meaning that those nursing homes that
experience a nursing staff position short on a given shift, or in fact
understaffed in general, are at great risk of cutting corners and providing
issues related to safety and quality of resident care
As care providers nursing homes are placed at risk of deregulation and losing
their registration if they are not able to fill nurse places to match rota needs
Conclusion
Nursing within the UK health care sector is currently experiencing a true crisis.
Estimates of supply and demand suggest that the short-sightedness of
commissioning decisions around nursing training within the UK will lead to a
shortage of 17,000 nurses by 2016. If the current inaction continues then this deficit
will rise to 80,000 by 2020.
This issue is currently only starting to be discussed by the sector however this may
be too late to rectify the situation. Recent reports suggest that there may be as many
as 20,000 full time nursing positions un-filled across the NHS. (This figure was
supported by the RNHA survey).It is very unlikely that there will be a sudden
increase in the number of nurses being trained by the British healthcare sector as
financial budgets continue to be stretched. This leaves only one other viable source
of nurses available to our country, Immigration from abroad. With countries across
Europe recovering from the economic crisis of 2008, the UKs ability to recruit from
within the EU or EEA will diminish over time. Meaning that significant and sudden
change will be needed within the health and social care system of the UK or the
number of nurses needed from outside the EU/EEA will need to dramatically
increase.
The numbers discussed within this paper are based on our current best estimates
and whilst the exact magnitude of the deficit in the number of nurses is difficult to
calculate exactly. It is not possible to suggest that the UK is producing enough
nurses to meet the future needs of the population. The only way to meet this demand
in the short to medium-term is through immigration to the UK of thousands of nurses
per annum.
As competition for UK-based nurses increases this will mean that the care home
sector will have to recruit much more actively from outside sources, either nurses
from the EU/EEA or from further abroad. The care home industry has needed to
recruit from outside the EU to maintain it’s existing cohort of nurses, as indicated by
the fact that a third of all nurses in our sector are from outside Europe. Therefore to
ensure that our sector is able to recruit enough nurses to meet future demand
barriers to recruitment from outside the EU/EEA must be reduced so that more
nurses can be recruited through this route, and is why the country needs to have
nurses on the shortage occupation list.
Further, we should not lose sight of the fact that they are net positive contributors to
society and not a net drain.
References
1. Workforce Plan For England 2014/15, Health Education England,
http://hee.nhs.uk/wp-content/blogs.dir/321/files/2013/12/Workforce-planinvesting-in-people.pdf
2. NHS QUALIFIED NURSE SUPPLY AND DEMAND SURVEY – FINDINGS,
NHS
Employers,
May
2014,
http://hee.nhs.uk/wpcontent/uploads/sites/321/2014/05/NHS-qualified-nurse-supply-and-demandsurvey-12-May1.pdf
3. Figures show the extent of the NHS reliance on foreign nationals, The
Guardian
Newspaper,
January
2014,
http://www.theguardian.com/society/2014/jan/26/nhs-foreign-nationalsimmigration-health-service
4. Nmds-sc briefing, Issue 21 – Registered Nurses in Adult Social Care, June
2013, https://www.nmds-sc-online.org.uk/Get.aspx?id=802623
5. A Hidden workforce crisis in the NHS, Royal College of Nursing, Nov 2013,
http://www.rcn.org.uk/newsevents/news/article/uk/a_hidden_workforce_crisis_
in_the_nhs
6. RCN responds to increase in nursing training commissions, Dec 2013,
http://www.rcn.org.uk/newsevents/news/article/uk/rcn_responds_to_increase_
in_nursing_training_commissions
7. Number of Foreign Nurses up by 50% in one year, The Telegraph, May 2014,
http://www.telegraph.co.uk/health/nhs/10828893/Number-of-foreign-nursesup-50pc-in-a-year.html
8. Centre For Workforce Intelligence (CfWI) Future Nursing Workforce
projections, June 2013, http://www.cfwi.org.uk/publications/future-nursingworkforce-projections-starting%20the%20discussion
9. Commons
Debate,
10
April
2014,
http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm140410/text
/140410w0002.htm
10. World
Health
Organisation,
Data
and
Statistics,
http://www.euro.who.int/en/health-topics/Health-systems/nursing-andmidwifery/data-and-statistics
11. These figures were calculated internally using figures from a number of
sources.
For
full
details
of
this
calculation
contact
[email protected]