More nurses leaving the profession than joining, figures show

My Post (10)More registered nurses are leaving the profession than joining, analysis by the Nursing and Midwifery Council (NMC) has revealed. First published in July, the data showed that the overall number of leavers has increased from 23 087 in 2012/13 to 34 941 last year (NMC, 2017a). By contrast, the number of initial joiners was 29 025 for 2016/17.

Jackie Smith, NMC Chief Executive and Registrar, said: ‘At a time of increased pressure on the healthcare workforce to deliver quality patient care, we hope our data will provide evidence to support government and employers to look in detail at how they can reverse this trend.’

Recent figures reveal that the number of registered nurses has continued to decline, with 27% more people leaving the register than joining between October 2016 and September 2017 (NMC, 2017b).

‘These alarming new figures represent a double whammy for the NHS and patients,’ said Royal College of Nursing (RCN) Chief Executive Janet Davies.

‘Not only has the number of UK nurses quitting the profession gone up, but significant numbers of EU-trained nurses on whom the health service depends are leaving and there’s been a huge drop in nursing staff coming to work here from EU countries.’

The number of nurses and midwives from Europe leaving the register has increased by 67%, while the number joining the register from the EU has dropped by 89%.

Although the NMC does not have separate figures for the number of practice nurses leaving the profession, records show that in March 2017 there were 15 528 full-time equivalent practice nurses. This represents a decrease of 225 since March 2016 (NHS Digital, 2017). The number of European nurses joining and leaving general practice is unclear.

Why are nurses leaving?

One of the key reasons nurses are leaving the register is because an increasing number are reaching retirement. Nurses of the ‘baby boomer’ generation are now able to claim their NHS pension, and many are choosing to do so. Under the NHS pension scheme, nurses who were working on or before 6 March 1995 have the right to retire at 55 without any reductions in their pension.

‘Nursing and midwifery are widely acknowledged to be ageing professions, with significant numbers on the register coming up to retirement age,’ said Ms Smith.

It is this factor, combined with increasing workloads, that is encouraging nurses to leave the profession early said Crystal Oldman, Chief Executive of the Queen’s Nursing Institute. ‘I think what’s happening is with the increasing demands on individual nurses in their areas of practice, those at that age—between 55 and 65—are saying, “you know what, this is not what I joined to do,”’ she said.

‘“I am not able to give the care that I used to be able to give, so I’m going to retire now. I’m not going to revalidate, I’ll come off the register, I’ll take my pension.”’

Jenny Aston, Royal College of General Practitioners Nurse Champion, agrees that retirement is the main reason for increasing numbers of practice nurses leaving. ‘The QNI survey that was done a few years ago suggests that there are about 30% due to retire in the next 2–3 years,’ she said. ‘That’s going to be a massive number, unless for some reason they wish to stay on or are encouraged to stay on.’

Valerie Ely, 58, is a registered nurse and senior lecturer at Huddersfield University who is in the process of taking voluntary severance. She went part time at 55, because to remain a manager she was required by the university to do a PhD.

‘I am sad about it and to some extent a bit bitter, but I am 58 so have to accept it,’ she said. ‘A PhD would be 6 years part time and it’s really performance managed.’

‘The irony of my redundancy date is that it’s the same day I would have had to renew registration and revalidate. I have not been clinical for some years and it’s unlikely I’m going to get a job at another university, so I don’t feel that I have many options to stay on the register,’ she added.

But not all those leaving are of retirement age. Of those who didn’t cite this as their reason for leaving, the average age has reduced from 55 in 2013 to 51 in 2017. Additionally, the numbers of leavers aged 21–30 years has increased from 1 510 in 2012/13 to 2 901 in 2016/17.

A survey of 4 500 nurses and midwives carried out by the NMC revealed that working conditions, a change in personal circumstances, and a disillusionment with the quality of care provided to patients were also cited as reasons for leaving.

Sarah is a lead practice nurse at a GP surgery in South Yorkshire. She has been a practice nurse for 9.5 years but is leaving to take up a respiratory nurse role at a hospital trust. She is hoping the new job will bring back her passion for nursing.

‘As nurses experience tougher work conditions, the importance of ensuring they are valued cannot be understated’.

‘Although I enjoy the variety within the role, I am increasingly feeling overwhelmed with the extent of the knowledge and skills I need to be competent to do my job,’ she said. ‘There are only two nurses at my surgery, so we both need to be able to do everything within the practice nurse remit.’

As nurses experience tougher work conditions, the importance of ensuring they are valued cannot be understated. Kathryn Yates, Professional Lead for Primary, Community and Integrated Care at the RCN, thinks that the feedback from patients, families and carers about the outstanding care they receive from general practice nurses is incredibly important.

‘We need to continue to raise the profile of general practice nurses and how valued they are,’ she said. ‘I think we need more evidence to support that.’

Additionally, Dr Oldman says that, due to increased workloads, many nurses are finding themselves no longer doing the job they were trained to do. This understandably causes frustration and a decrease in job satisfaction. ‘They may not be leaving if the conditions were suitable for them to give the best possible care they want to give,’ she said. ‘We have a lot of anecdotal evidence from nurses who say, “I would stay, but I can’t do the job I was trained to do.”’

This lack of being valued is at the heart of why Sarah decided to leave practice nursing. ‘There is a lack of understanding and awareness of what practice nursing involves, which has an impact on others’ expectations,’ she said. ‘It is viewed by the public and other nurses/health professionals as an easy job, with nice hours and none of the pressures that are obvious in hospitals, emergency departments etc.

Our contribution is usually overlooked or any achievements attributed to GPs.’

Combatting the problem

Central to the issue of recruitment and retention is a workforce plan that ensures there are sufficient numbers of nurses now and in the future. A clear workforce plan also allows for accountability when those numbers aren’t met.

Crystal Oldman said: ‘I think the issue is about having a robust workforce plan and also having accountability for that somewhere centrally. Each individual provider must have its own workforce plan, but we are a national health service. What I would like to see is a national workforce plan for registered nurses.’

Kathryn Yates supports this but adds: ‘If we signpost to one particular organisation, it may devolve responsibility. I think there is also a sense of being mindful of how organisations work together to try and come up with real-time solutions.’

For Jenny Aston focusing on training the next generation and making nursing an attractive career is key. ‘Nursing isn’t going to change over the next 10 years: there are still going to be injections, there is still going to be lots of wound care, there is still going to be a need to monitor patients’ health,’ she said. ‘The work is not going away. There may be bigger practices, but I don’t see the nursing activity changing and, therefore, there is going to be an ongoing need to train up the next generation because 30% are going to be retired in 3 years’ time.’

Additionally, there need to be incentives for nurses not to retire early. ‘What lots of people don’t realise is that there are ways to stay on, claim your pension and make your pension arrangements different, so you don’t lose out on the final salary [pension benefits],’ said Ms Aston. ‘But I don’t think many nurses have good financial advice on how they get the best out of staying in work.’

Most importantly, nurses have to be listened to, so their concerns are understood and they feel valued. According to Kathryn Yates, it may be unclear what their needs are: ‘Going forward we may have a workforce that wants to work differently, and we must continue to make nursing an attractive and first destination career.’ she said.

Maria Caulfield, former nurse and Conservative MP for Lewes, said: ‘While I welcome the fact that more nurses are entering the profession than ever before, I am concerned that we are losing large numbers of our most experienced nurses, who are retiring or leaving the profession early. As a result, overall nursing numbers remain static at a time when the demand and need for nurses are increasing. There are a variety of reasons why nurses are leaving and certainly the pay freeze and cap have not helped morale, but from talking to colleagues it is the lack of overall recognition and feeling of worth that has led to many walking away. This is why I have lobbied ministers to ensure nurses are recognised. Lifting the pay cap is one way to show this.’

Health Education England oversees education and training of NHS staff. It has identified the need for additional supplies of nurses and improved rates of employment for graduates. Closing current shortages will also help with moderating increasing workloads.

NHS Improvement has launched a programme to improve retention of NHS staff by 2020. It will look at reasons why staff are leaving to help understand how to improve retention rates.

References

NHS Digital. General and Personal Medical Services, England March 2017. https://digital.nhs.uk/catalogue/PUB30044 (accessed 13 December 2017)

Nursing and Midwifery Council. The NMC Register: 2012/13–2016/17. 2017a. https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/nmc-register-2013-2017.pdf (accessed 13 December 2017)

Nursing and Midwifery Council. The NMC Register: 30 September 2017. 2017b. https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/the-nmc-register-30-september-2017.pdf (accessed 13 December 2017)

British Thoracic Society/Scottish Intercollegiate Guidelines Network. SIGN 153. British guideline on the management of asthma 2016. 2016. https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (accessed 19 December 2017)

National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. 2017. https://www.nice.org.uk/guidance/ng80 (accessed 19 December 2017)

Taken from Practice Nursing, published January 2018.

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Hunt challenges the NHS to deliver digital services by 2018

Adobe Spark (6)The Health Secretary, Jeremy Hunt, has challenged the NHS to deliver digital services nationwide by 2018 to coincide with the NHS’ 70th anniversary next year.

Hunt used September’s Health and Care Innovation Expo in Manchester to highlight the opportunity of technology in creating ‘The patient power decade’. The Health Secretary painted a pixelated portrait of a future shift in power within the NHS from doctor to patient, with the patient ‘Using technology to put themselves in the driving seat of their own healthcare destiny.’

Hunt stated that by the end of 2018, patients will be able to use an integrated smartphone app to access services such as NHS 111, book a GP appointment and even have the ability to view healthcare records online.

Currently, according to NHS Digital, 680,000 patients are viewing their medical records online every month.

In this keynote speech, he further acknowledged how ‘People should be able to access their own medical records 24/7, show their full medical history to anyone they choose and book basic services like GP appointments or repeat prescriptions online.’

Mr Hunt also stated that the app could be used to order repeat prescriptions, access support for managing long-term conditions, or express preferences on organ donation, data sharing, and end-of-life.

Hunt emphasised how the ‘master-servant relationship’ between doctors and patients that has existed for three millennia will be ‘turned on its head’, and patients will use the information that becomes available at their fingertips, ‘to exert real control in a way that will transform the prospects of everyone.’

Overcoming hurdles

If the NHS is to successfully deliver digital health services, there are a number of potential hurdles to overcome. Firstly, there are concerns over the accessibility of services for those unfamiliar with smartphone technology, or from those of disadvantaged backgrounds who cannot afford to buy a smartphone. For this reason, Hunt stressed how the new services will be for everyone:

‘If the NHS is not there for everyone, it is nothing,’ he said. ‘We recognise that not everyone is comfortable using a smartphone. So we will always make sure that when we introduce new services, there is a face-to-face or telephone alternative, for people who do not use smartphones.’

While many older people struggle with online technology, it is worth pointing out this is not always for want of trying. Hunt outlined how 400 000 people have already been trained to help get them online, and over the next 3 years, a further 20 000 digital inclusion hubs will be rolled out. Additionally, wifi will be introduced across primary care this year and secondary care next year, which is hoped will help support people accessing online resources.

Secondly, in lieu of the NHS cyber attacks earlier this year, Hunt conceded that a lot needs to be done to win back the public’s trust:

‘We have to recognise that we still have a lot to do to earn the public’s trust that their patient data is safe with us,’ he said.

As part of this, the Government announced its response to the National Data Guardian and Care Quality Commission report on data security in July. Among the initiatives are 10 new data security standards, a £21 million investment to protect trauma centres from cyber attack and new national support for unsupported Microsoft systems that were part of the original problem that caused the cyber attacks.

The role of mobile technology in delivering health services was also highlighted in a keynote speech from Professor Sir Bruce Keogh, medical director of the NHS. He said we run our social lives, financial lives, travel lives and retail lives online, so why not our health? Keogh welcomed the idea of being able to book GP appointments, get blood results or see X-rays online. However, he also recognised that it brings with it some challenges.

The first challenge is digital therapy, particularly in the area of mental health. According to Keogh, this will involve activities patients can do on their mobile phone that will improve their health, such as talking therapies, so that they do not have to visit a psychologist, psychiatrist or your GP. The NHS will have to work out how it assesses these, but importantly it needs to work out the payment mechanisms behind them so that they are available for everyone on the NHS.

The second challenge concerns what happens when people can get advice and treatment outside normal geographical boundaries. Currently, the way the NHS is structured means a GP is determined by where a patient lives. However, Keogh highlighted how already many are visiting GPs outside the area where they live. He therefore questioned what happens as more people start to access health care not just beyond their local area but beyond their regional area and possibly internationally. He stressed the need to work out who pays for what, the duties of Government and arm’s length bodies with respect to ensuring the safety of those transactions, and the legal implications. The issue is how this can be made part of the NHS, rather than creating a two-tier ‘pay for it if you can’ service.

Looking to the future

Pilot schemes are already underway, with ongoing evaluation before the digital service is introduced nationally. According to Hunt, initial results from pilots in north London, Leeds, London and Suffolk, show that when NHS 111 services are transferred online it is safe. He also pointed out that if digital health services are introduced in the right way, it will save the NHS money. He said: ‘The 6% of people who use the 111 app, rather than speaking to the call handler, save the NHS money. That’s more resources for doctors and nurse.’

Looking to the future, Hunt confirmed that the Government are trying to build the safest, highest quality health system in the world. The role of technology, therefore, is one that he believes is of the utmost importance in making this a reality:

‘As we grapple with the challenges of resources, challenges to improve patient safety, challenges to improve quality and challenges to improve changing consumer expectation, technology can be our friend if we recognise it as a means to an end and not an end in itself, and that end is safer, healthier patients,’ he said.

Taken from British Journal of Healthcare Management, published October 2017.