Steve Fouch

Where have all the nurses gone? NMC survey reveals an accelerating attrition of nurses and midwives

Steve Fouch is CMF Head of Nursing, and formerly worked in community nursing, HIV & AIDS and palliative care. He serves on the International and European regional boards of Nurses Christian Fellowship International.
The views expressed do not necessarily reflect those of CMF.

It seems sadly ironic that a week after Lord Crisp announced plans for a worldwide campaign to promote the value of nursing in global health and development, the UK’s Nursing and Midwifery Council announced that in the last year 1,783 more nurses and midwives have left the professions than joined for the first time in over a decade.

Inevitably this has fed into the current calls for an end to the public sector pay cap, for more certainty about the future of EU nationals working in the UK after Brexit, and to reinstate bursaries for student nurses, etc.

Dig into the figures however, and a more complex picture emerges. Not least is that this is not a new story – the concerns about training, recruitment and retention of nurses and midwives go back several years.

First, those that are leaving in largest numbers are nurses first registered in the UK. Of the 35,000 nurses and midwives leaving the register in 2016/2017, over 29,000 were British. We have known for some time that fewer EU nationals are applying for nurse jobs in the UK, and many are leaving. However, EU nationals make up barely 4% of the nursing workforce. Filipinos, Pakistanis and Indians are a bigger proportion of the workforce, and NHS trusts are increasingly going to those countries to recruit.

However, over 85% of nurses and midwives working in the UK are British nationals. This then is not primarily a Brexit crisis, although uncertainty around Britain’s departure looks to be a minor contributory factor.

Second, among those who have been surveyed about their reasons for leaving, pay was not the primary cause. About half are leaving because of retirement, and of those leaving for other reasons, only 18% rank pay and benefits as their main reason. Working conditions, including staffing levels, were the biggest reason for non-retirees leaving the profession.

But the main reason most give for leaving is stress and finding the workload, short staffing and pressures too much to manage (44% of those leaving for reasons other than retirement).  Secondarily, many cite that not being able to give the level of care they want to because of these pressures has made it impossible for them to carry on their work. New research suggests that the prevalence of twelve hour shift patterns is adding to this unmanageable stress load. When the very nature of the system stops health professionals from feeling able to do their job properly, then questions need to be asked.

The Government says that there are more than 13,000 more nurses working on our wards than in 2010, and that there are 52,000 students in training. However, with an estimated 40,000 nursing and 3,500 midwifery vacancies unfilled in England alone, those assertions are disputed. It is therefore not too hard to see why staffing is a contributory factor in workplace pressures.

More troubling still is the profile of those leaving. The average age is 51 – that’s four years younger than the average age of leavers in 2012-2013. We have long known that we are facing a retirement cliff edge, with one in three nurses due to retire in the next decade. Thus the majority of those leaving are experienced, skilled nurses and midwives. That experience is not quickly replaced, and the attrition of experienced, skilled staff will have a real impact. The even bigger worry though, is the number of younger nurses that are leaving. This has doubled in the last three years. This means fewer staff building up the skills and experience in the long-term to replace those reaching retirement.

The other concern is the reduction in people applying to train as nurses or midwives. Since the abolition of bursaries last year, there has been a 23% drop off in applications. Anecdotal evidence suggests that tuition fees and stacking up major debts to train for a relatively low paid job is putting off many prospective students. Whether the shortfall continues past this year we wait to see, although the government remains confident that student numbers will pick up over the next couple of years. Whether there will be the funding for clinical placements for those students is another issue vexing universities.

Finally, the survey reveals that about 4,000 nurses and midwives have left the UK to work overseas. In particular they are heading off to Australia, the USA and Ireland. While the UK has been a net recipient of migrant nurses over the years, are we now moving towards being more of an ‘exporter’? This also highlights how internationally mobile the nursing workforce is. If the UK does not provide the best work environment, many will up stakes and move to parts of the world that offer better working conditions and pay. The NHS has to compete globally for nurses and midwives.

This is a complex issue that has been brewing for many years. As I said, it is also ironic that a parliamentary committee produced a report not twelve months ago that showed the way to improve a nation’s health, economic and social development and improve the status of women, was to invest in nursing and midwifery. Despite successive British governments promising that they will do / are doing this, the evidence is stacking up that they have not really succeeded.

Where do we go from here?

We can continue to recruit from non-EU countries. While this has benefits, it also adds to the brain drain from many developing nations. The nursing workforce is globally much smaller than needed. Our struggle to recruit can only be addressed in the long-term by tackling this global nursing shortage.

We could invest in training nurses and reinstating bursaries, but we were already struggling to fill nursing places before bursaries were introduced. We could scrap the 1% public sector pay cap, but this would cost the government £9 billion according to the IFS, and for now the government is ruling that out as an option.

The question is, as always, from where will the money come to pay for any or all of this? So the first issue to address is, what kind of healthcare system do we need, and how are we willing to pay for it? The answers today will be quite different to those raised at the birth of the NHS in 1948.

Second, the core values of the nursing profession are deeply Christian in their origins. However, the increasingly technical, acute and high throughput model of medicine under which the NHS operates makes this hard to live out in practice. This dissonance between the values of patient centred, whole person care on the one hand and a technological, protocol driven medicine on the other is increasingly difficult for nurses (and other health professionals) to live with. Until we can address this dissonance and answer what kind of model of health care we really want and can deliver, we will continue to struggle with a long-term solution.

In the meantime, the church can do a lot to support its own health workers – spiritually through flexible worship and home/prayer group arrangements that take into account shift patterns and anti-social hours, and creating groups specifically for health professionals to support one another.

Churches can be sources of encouragement and thanks to the wider community of NHS staff – making sure that health professionals and other NHS staff in their communities get thanks and encouragement regularly for the work they do.

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