Pay alone is not the answer to the UK’s nursing crisis – it’s far more complicated

Picking a row with nurses on pay after the events of the last year was a curious move by the government. Unions are preparing to fight ministers who say they are determined to not concede.

“The PM will only get – and keep – the extra staff our patients need by also committing to a significant pay rise,” said Royal College of Nursing chief Donna Kinnair earlier this month, as the union demanded a 12.5% average pay rise above the government’s planned 1% increase.

But behind the dispute lies a complex dilemma for the NHS. Getting the numbers right is proving difficult. With the number of British applications to study nursing consistently higher than the number of places available, the chronic shortage in the NHS of trained nurses cannot be explained by the wage question alone.

A record number of British school leavers applied to nursing courses this year according to the latest figures from UCAS, the undergraduate application portal. The number of students over 35 applying for nursing courses passed 10,000 for the first time.

The spotlight shone on nursing by the pandemic only partly explains the upsurge. The latest figures brought the total number of applications back to the level before 2017, when the government scrapped the NHS Bursary Scheme for nursing training. A new annual bursary of £5,000 has now been reinstated. The Royal College of Nursing is now calling for “full tuition funding and living costs support” to persuade others into the profession.

Nursing shortages have accounted for half of all NHS vacancies since 2015, with over 38,000 unfilled positions in England alone last year. The government has pledged to recruit 50,000 more by 2025. Declining real wages may have indeed squeezed people out of the profession.

“Recent research has shown that over the last 10 years, in the wider economy, in real terms, wages have gone up by 3%. For NHS staff as a whole, they’ve gone down by 2%”, says Nihar Shembavnekar, an economist at the Health Foundation, a UK charity and public health think-tank. “That’s a hugely worrying factor.”

Nursing is facing a retention problem, with UK-trained staff representing over 83% of those leaving the national register in 2019 compared to 74% of those joining, according to analysis by the Royal College of Nurses. Nearly one in four entrants to the register in 2019 were recruited from outside the European Economic Area, rising to nearly one in three in 2020.

According to a report by The King’s Fund, an independent health charity in England, the government will have to recruit a further 5,000 nurses from overseas each year until 2025 to meet rising demand. The government’s decision in February to further ease restrictions on foreign recruitment led the Royal College of Nursing’s General Secretary to warn that it should not “substitute for adequate training, education and investment” in the UK.

But the government faces a long-term, multi-dimensional problem: how to allocate scarce public resources to retain current nurses, while training new ones; and to coordinate with a host of organisations, including NHS trusts, universities and recruiters, to ensure demand is being met across the country.

According to analysis by the Health Foundation, of the four main nursing sectors, only adult and child nursing have seen increases in staff numbers since 2010, with numbers in mental health and learning disability nursing, which both require specialist training at UK institutions, both down on ten years ago.

On foreign recruitment, Shembavnekar says that while it can provide a “quick fix” for short-term shortages, it will not be able to meet growing demand for specialisms such as mental health nursing in the coming years.

Allocating nurses is made more difficult by a lack of central planning, he says. “There is a lack of clarity about which organisations and stakeholders are responsible for different parts of the system. In London, for example, the pay increase required to incentivise nurses to stay and work in an NHS branch is much higher than in an area with lower living costs.”

This lack of coordination extends to the education system. The NHS employs around three in five of its nurses from British universities, however some enter via apprenticeship schemes. Drop-out rates average 24% and it is unclear how far these impact on high-demand specialisms such as mental health nursing, because central data is lacking.

The university system has historically been hampered by poor planning, says Alex Baylis, assistant director of policy at the King’s Fund.

“Until recently, for example, Health Education England was responsible for managing university placements, but not for clinical placements, which you need to train nurses. So we had a break in the system which meant that even if Public Health England wanted to commission more university places, they didn’t have the coordination to do that. That’s one of the single biggest reasons why places aren’t available.”

Despite recent criticism of the government’s pay increase, then, NHS income is less of a funding priority than boosting training capacity. UCAS received over 62,000 applications for nursing courses in 2020, higher than the two previous years, but only 3 in 5 were accepted.

While place numbers have risen by 56% since 2013, the UK remains the OECD country with the highest number of overseas recruits, with 15% of registered staff having been trained outside the UK.

To meet the government’s 50,000 recruitment target by 2025, there is an acceptance that international recruitment from outside Europe – especially from India and the Philippines – will disproportionately increase. A report by the Migration Advisory Committee in 2019 showed that, accounting for other characteristics, nurses recruited from overseas were paid a fifth less on average than their peers because they are usually placed on the lowest end of the pay-scale.

As hospital demand increases in the post-pandemic period, with cancer and mental health care top of the agenda as the virus fades, wage disputes will therefore be only one part of a broader debate.

Shembavnekar is working with the Health Foundation to develop a Nurse Supply Model to gather data on nurse recruitment and allocation, to help health authorities work out how to allocate staff training. “The model will allow us to look at changes to policy on the domestic training front and international recruitment, and how that plays into different nurse numbers over the next twenty years,” he says.

In the short-term, Baylis warns, that means “we can’t just turn off the tap for international recruitment”.

“If we continue training staff for the next ten years, we should be able to close the gap on current vacancy levels,” he says.