Nurse Training

Jim Shannon Excerpts

Wednesday 5th September 2018 Commons Chamber

[Richard Drax (South Dorset) (Con)]

It is a great privilege to be drawn for one of these end-of-day Adjournment debates, as they give Back Benchers such as me the opportunity to debate a subject dear to their heart. Tonight’s topic is fairly dry, but it is very important. I hope the House and those watching will forgive me if I plough into a lot of detail, because the detail is important on this issue. I welcome the Minister, for whom I have a high regard, to his place. Another advantage of these debates is that the poor Minister has to sit there and listen to me, and there is nothing he can do—he cannot escape. So I hope my words will fall on receptive ears.

This debate follows a recent public meeting on Portland hospital in my constituency; the beds at the island’s much-loved community hospital have been closed, but more on that shortly. We have heard it before, and it needs to be said again: we are facing a desperate shortage of nurses. Health Education England believes there are 36,000 nursing vacancies in England, whereas the Open University says it is 38,000 and the Royal College of Nursing gives a figure of 40,000. That last figure equates to an 11% vacancy rate, with learning disability and mental health nursing the most affected, followed by community nursing. These gaps may be filled by bank or agency staff on a temporary basis, but Health Education England estimates that 1% remain permanently unfilled. The knock-on effect places nurses under “relentless pressures”, according to a report this January by the Select Committee on Health. It added that

“nurses felt their professional registrations were at risk because they were struggling to cope with demand.”

Meanwhile, any increase in nurse numbers is swallowed up by the demand for more of them. For example, although the number of new nursing positions created between 2012 and 2015 rose by 8.1%, the number of those who actually joined the profession increased by only 3.2%. What is the consequence? Well, obviously, costs rise. Temporary nursing staff are expensive, with NHS trusts paying an average of 61% more for every extra hour they worked compared with that paid for a newly qualified, full-time, registered nurse. A Freedom of Information Act request by the Open University in January revealed that, if the hours worked by temporary staff were instead covered by regular nurses, the NHS could save as much as £560 million a year. The independent health think-tank, the King’s Fund, revealed that on average NHS trusts were spending nearly 7% of their salary budgets on agency staff, with the figure rising to more than 25% in some cases. Dorset HealthCare, which covers my constituency, forecasts an overall spend of £4 million this year on agency staff alone. That is down from a staggering £12 million three years ago but still represents a significant share of the healthcare budget.

As I mentioned at the start, 18 beds were closed at Portland Community Hospital last month due to a lack of nursing staff.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for giving way: I sought his permission to intervene beforehand. He is outlining the shortage of nurses in his constituency, but there are nurse shortages in many other parts of the United Kingdom, including in Northern Ireland, which has a shortfall of some 1,800 in nurse numbers. Does he agree that the training of nurses must be a priority for trusts and the Department of Health and Social Care? Part of the way to attract new nurses is to show how we value our current nurses through decent pay and working conditions. It is important to ensure that nurses are regarded highly for the work that they do—and paid accordingly.

[Richard Drax]

I do not disagree with anything that the hon. Gentleman has just said, and I will come on to his points a little later in my speech. Of course all nursing staff should be appreciated and paid properly. One of the issues, as I shall describe in a minute, is the work environment, which is one of the factors leading to fewer nurses—or insufficient numbers—entering the profession.

Before the intervention, I was talking about my community hospital in Portland, where almost half of all nursing positions were unfilled this summer. Agency staff, costing as much as £58 per hour—and £135 per hour on bank holidays—were still hard to find. The trust’s chief executive, Ron Shields, for whom I have enormous respect, decided he could no longer safely keep the beds open. So, despite the understandable protestations from islanders who wish to keep their frail and elderly relatives close by, the beds were migrated to a hospital in Weymouth, where the nursing staff available can be consolidated. I suspect that that situation is not uncommon across the rest of the country.

The crux of the matter is the recruitment and retention of nurses. Recruitment depends mainly on training new nurses for the future. The numbers required are traditionally set by Health Education England, which then commissions the nursing places from further education and training establishments, including colleges, universities and the Open University. Standards are set and approved by the Nursing & Midwifery Council, ensuring uniformity across providers. Those establishments, in turn, invite applications, for registered nurses, nursing associates, nursing apprenticeships and Nurse First.

The first role requires a degree, the second a prior healthcare qualification, the third is a joint initiative between individual health trusts and further education establishments and the fourth is a new initiative for high-flying graduates and follows the lines of Teach First. The three-year degree option remains the main route into nursing. While many, including me, dispute the need for a degree, the Nursing & Midwifery Council says that that is to misunderstand modern nursing. Registered nurses are now an “officer class”, according to Geraldine Walters, the NMC’s director of educational standards, with much of the work for degree-level nursing now highly technical and demanding. In some cases, registered nurse prescribers replace doctors and indeed even run their own primary care clinics in London.

So far the nursing associates programme has been a success. In December 2017, 2,000 nursing associates were in training. This year, it is hoped that figure will be 5,000, rising to 7,500 in 2019. The Nursing & Midwifery Council is clear that more recruitment and widened access into nursing training are essential, as is the diversity of training provision.  The Open University, for example, provides for those who, for a variety of reasons, would not gain access to the profession via the traditional, campus-based route.

Since 2002, the Open University has offered a four-year registered nurse degree apprenticeship in addition to the straightforward apprenticeship. This is aimed specifically at existing healthcare support workers who welcome the chance to earn while they learn. So far, it has trained more than 1,000 applicants as registered nurses, with 940 more currently on the programme in England. One huge benefit to the scheme is that participating trusts seem better able to retain the nurses they have trained. Compare this with the 24% drop-out rate for student nurses on the degree course. As the NHS is the nation’s biggest contributor to the 5% apprenticeship levy, it would be odd for it not to participate.

The loss of the bursary scheme has been keenly felt, with the Royal College of Nursing saying that it is a serious own goal. It was a support package including tuition fees, a non-means-tested maintenance grant, a means-tested bursary itself, and other elements designed to help students with placement, travel and childcare costs. It was overwhelmingly popular, attracting more applicants than there were places. It was replaced by the student loan scheme, requiring students to borrow money to pay for their training.

The problem is that nursing is a vocational training and does not cater for school leavers unsuited to the profession. Significantly, following the removal of the bursary, the number of applications for nursing through UCAS has fallen by a third since March 2016. Although the Department of Health and Social Care says that there are 52,000 nurses in training—more than ever before—the number of those accepted on to courses is still down by 9.3% in England. That threatens the pipeline of new nursing talent and, at the very least, should and could have been anticipated. Much-needed mature applicants, many with care experience, are also deterred by the burden of debt and loss of earnings, and Ms Walters told me that these are exactly the people the profession needs. Mature applicants also tend to choose careers in specialist areas worst hit by the staffing crisis, such as learning disability and mental health.

New figures from UCAS show that applications for nursing degrees and from mature students are down by 33% and 42% respectively since March 2016. As the latter group are the very people who would be grateful for any support given, and probably remain in the organisation until retirement, Mr Shields suggests that trusts should provide some form of financial support in the absence of bursaries. A recent survey by the Open University showed the effect of the loss of the bursary on recruitment. Only 30% of nurses asked said they would have been willing to self-fund or partially self-fund their initial nursing education. In addition, more than half of those surveyed believed that applications would continue to fall.

Attracting nurses back into the NHS after they have left is another crucial focus for recruitment. The return to practice campaign, run by the Nursing & Midwifery Council, which provides refresher training and a re-entry route back into the NHS, has already recruited almost 2,500 former nurses and is currently registering another 1,800. However, as the Health Committee report states,

“too little attention has been given to retaining the existing nursing workforce, and more nurses are now leaving their professional register than are joining it.”

The Committee cites many causes, including workload pressures, an inability to meet patient expectations, concerns about providing adequate care, poor access to continuing professional development, poor organisational culture, pay restraint and budget cuts. The impact of Brexit was another reason, although—interestingly—briefings from the Library show that overall EU staff numbers in the NHS have, in fact, fractionally risen since the referendum, with numbers of EU nurses falling by just 0.3%.

Another issue is the current pensions arrangements. Senior and experienced staff who might want to work beyond 55 are leaving because their pensions reduce in value if they stay on. Mr Shields has recently lost two senior and valued members of his team, and believes the Government must look at this urgently.

A partial solution to increase nurse numbers is to recruit from abroad, including Commonwealth countries. However, this was, until recently, severely limited by immigration rules, which were wisely relaxed in June after an intervention by the Home Secretary.

In December 2017, Health Education England published its draft health and care workforce strategy for England to 2027. “Facing the Facts, Shaping the Future” anticipates a significant shortfall in nursing numbers due to an increase in the number of posts needed. The Health Committee has emphasised that future projections of demand for nurses should be based on demographics rather than on affordability alone. A final workforce strategy is expected from Health Education England at any minute. Perhaps the Minister can enlighten us, as it was expected, as I understand it, at the end of July.

Finally, I thank all those who work in our NHS for the wonderful job they do, not least the fantastic teams in South Dorset.