The RCN’s latest survey on workplace staffing levels in the NHS offers sobering evidence of how one of the Tories’ 2019 manifesto commitments – to employ 50,000 more nurses by 2024 – has done little, if anything, to lessen the impact of nursing shortages on patient safety, or to address the reasons behind those shortages.

Among the findings of the RCN survey of its 20,000 members were the following:

84 per cent said staffing levels on their last shift were not sufficient to meet all the needs of patients safely and effectively;

only 25 per cent of shifts had the full number of planned registered nurses;

– just one in five respondents agreed they had enough time to provide the level of care they would like, with four in five judging that patient care was compromised due to not having enough registered nurses on the shift; 

– more than 40 per cent of respondents said that due to lack of time they had to leave necessary care undone; 

– almost two thirds of respondents worked additional time and, of these, almost eight in ten were unpaid for these additional hours; 

– most shifts reported in 2022 worked with between 50 per cent and 74 per cent of the planned registered nurses, which is below the 80 per cent threshold stipulated by the RCN’s nursing workforce standards;

Chillingly, in a report the RCN published earlier this year it noted that, “There is a clear body of evidence that shows a direct link between nursing staffing levels and patient safety outcomes. This includes evidence that for every day that a patient is on a ward with fewer nurses than average, the chance of the patient dying increased by three per cent.”

As if on cue to reinforce the RCN’s messaging, news emerged earlier this month of critical problems at two major hospitals: 

A nurse was filmed warning patients at an overcrowded A&E department at the Princess Alexandra hospital in Harlow that they might have to wait up to 13 hours before they were seen, because there were already 170 patients in the department, with 90 more waiting. The video was shared on Twitter by the father-in-law of one patient who, having witnessed the nurse being verbally abused by other patients, later told the Guardian, “It’s a tragedy and I feel a mixture of sadness and anger. When I read of [health secretary Sajid Javid’s] promise of a ‘Netflix’ NHS I decided it was time to drop a truth bomb on their bullshit.”

In the same week, the Care Quality Commission (CQC) warned of “significant” safety concerns at the York Hospital, run by the York and Scarborough Teaching Hospitals NHS Trust. Noting that some patients had been left unwashed for three days, the CQC echoed the results of the RCN survey, saying, “The service didn’t have enough nursing staff with the right skills, training and experience to keep patients safe and to provide the right care and treatment.”

The much-hyped ‘50,000 by 2024’ recruitment target was justifiably met with scepticism three years ago, when it was revealed that only 31,500 nurses would be newly recruited, with the balance of 18,500 made up by those already employed in the health service, and who would simply be “retained” by the NHS. The government claims that 27,000 new staff have so far been recruited under this programme.

However, in 2022 the nursing sector still has a vacancy rate of around 39,000 – equivalent to ten per cent of the workforce – and retention rates are faltering. The number of professionals leaving the Nursing & Midwifery Council’s register (ie some of the 18,500 the government is surely hoping to retain) is up, year-on-year, and one in five nursing registrants is aged 56 or older – and therefore likely to retire within the next few years, especially as pressures intensified by the pandemic take their toll on staff wellbeing.

And government statistics on nursing recruitment often fail to acknowledge an increasing and long-standing reliance on hiring from abroad to plug gaps in the domestic workforce, often to the detriment of other countries’ health services. There has been a ten-fold increase since the 2019 general election in the number of nurses joining the register from countries currently identified as having the most severe workforce shortages.

Only 56 per cent of those joining the nursing register in 2021 were educated and trained in the UK, reflecting the Tories’ aspiration that 12,500 of their 2019 manifesto target of 50,000 nurses were always planned to be international registrants. 

In April new research from the King’s Fund thinktank concluded that the nursing workforce shortage is set to remain severe, regardless of whether the government reaches its headline-grabbing targets, because demand is rising faster than nurses can be trained or recruited – mainly due to the growing care backlog and new targets for diagnostic and elective procedures.

Poor remuneration must surely play a part, too, hitting both recruitment and retention rates. With nurses struggling to pay their rent or afford the petrol they need to get to work, it’s obvious that they need to be paid more, but the government appears determined to push through a miserly 3 per cent settlement in the latest pay review for NHS staff – despite inflation hitting 9 per cent. This intransigence comes against a background of health service pay having stalled for more than a decade, with the TUC calculating that nurses are now £5,200 worse off compared with 2010, when pay is adjusted for inflation.

The UK already ranks below the average of high-income OECD countries in terms of both the number of practising nurses and the annual number of new nurse graduates, relative to its population. It has just under eight practising nurses per 1,000 population, while the OECD average is nine. Germany has more than 13 nurses per 1,000, while Australia has 12 and Belgium and the Netherlands each have 11.

More narrowly, in the UK, in specialisms such as community nursing, mental health nursing and learning disability nursing, the numbers are all already lower than they were in June 2010, according to the Health Foundation. And just last month Royal College of Midwives chief executive pointed up a shortage of more than 2,000 midwives in England alone.

Crucially, inadequate workforce planning may be the root cause of many problems within the NHS, but it’s an issue the government seems reluctant to engage with. The Health Foundation, the King’s Fund and the Nuffield Trust have lobbied long and hard on the issue, and collectively published concrete proposals three years ago which had a minimal impact on official thinking. 

That leaves the health service with little more than the 2022-23 NHS Operating Framework, which merely commits NHS England to “work with systems to develop workforce plans”. Last month Health Education England chief executive Dr Navina Evans told the Commons Health and Social Care Committee (HSCC) that her organisation’s forthcoming ‘Framework 15’ will simply look at “what the population needs” and “what work needs to be done”. She added, “It won’t tell us exact numbers, but it will tell us how we need to think about and what will be required as a continuous, iterative process.” 

This flummery prompted committee chair Jeremy Hunt to counter, “I am deeply sceptical of publishing a framework – that’s like saying we’re going to publish an algorithm, but not an answer… Isn’t it actually basically useless to publish a document on the biggest crisis facing the NHS if it doesn’t give a simple answer that the public understands on whether or not we’re actually training enough doctors and nurses for the future?” 

Such cynicism was unsurprising – given that in February this year the government rejected HSCC’s plea to alleviate the workforce crisis in the NHS by overhauling its approach to workforce planning, and later (in April) twice rejected an amendment to the forthcoming Health and Care Bill that would have forced it to publish regular, independent assessments of how many doctors and nurses the NHS actually needs.

Little wonder then that, in the same month, the RCN membership survey showed that, compared to before the pandemic, 74 per cent felt more valued by the general public, 54 per cent felt more valued by patients – but only 18 per cent said they felt more valued by the government.

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