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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Government’s additional £1.3 billion for mental health services is misleading

Adobe Spark (4)The Government has committed £1.3 billion to transform mental health services by 2021 (Health Education England (HEE), 2017). Stepping Forward to 2020/21: Mental Health Workforce Plan for England was launched by Health Secretary Jeremy Hunt, who called it ‘one of the biggest expansions of mental health services in Europe’ (Department of Health, 2017). The funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services.

Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

Examining the plan

The scale of these proposals is commendable and reflects the additional staff required to deliver the transformation set out in The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016). Mental health provision has consistently been underfunded, therefore an update to place it more in line with physical health provision is long overdue.

For this reason, the announcement has been welcomed by many mental health campaigners and professionals. The Royal College of Psychiatrists (RCP) led the way in commending the Government’s plans, with Professor Wendy Burn, President of the RCP, saying the 570 extra consultants promised in the strategy will be ‘crucial to delivering the high-quality, robust mental health services of the future’ (RCP, 2017). NHS Employers said service providers will welcome national support, particularly for ‘improved access to funding for continuing professional development for the mental health workforce, and facilitating increased use of international staff where required’ (NHS Employers, 2017).

However, despite the will to welcome these proposals it would be wise to take them with a pinch of salt. While the Royal College of Nursing (RCN) encouraged the investment, it said the Government’s proposals ‘appear not to add up’ (RCN, 2017). RCN chief executive, Janet Davies, stressed that in order for the nurses to be ready in time, they would have to start training straight away. Additionally, she cites how the scrapping of nursing bursaries has led to a ‘sharp fall in university applications’.

Attrition rates on the rise

Attrition rates for all mental health staff are rising. From 2012/13 to 2015/16, the number of people leaving mental health trusts has risen from 10.5% to 13.6% (HEE, 2017). The NHS currently funds over 214 000 posts to provide specialist mental health services in England. However, over 20 000 of these vacancies are predominantly filled by bank and agency staff (HEE, 2017). It is clear the sheer scale of growth cannot be met via the traditional training routes within this timescale, as in some cases this would mean doubling or trebling the workforce. While investment is needed in the development and reskilling of existing staff, or looking to the global market for recruitment, this is an unrealistic aim.

The Royal College of Occupational Therapists (RCOT) is one of the groups who have raised concerns over vacancy rates. Julia Scott, CEO of the RCOT, said health and care services across the country are experiencing real difficulties in filling existing vacancies, with vacancy rates for occupational therapists of up to 50% (RCOT, 2017). She stressed that rapid action is needed to address this crisis if commitment is to be delivered.

The British Medical Association (BMA) echoed worries over recruitment, stressing insufficient psychiatry trainees across England and a high percentage of trainees not completing training in the specialty. BMA consultants committee deputy chair and consultant child and adolescent psychiatrist, Dr Gary Wannan, said: ‘In 2014, one in five doctors undertaking core psychiatry training did not progress into the final part of their training’ (BMA, 2017).

Government pledge still insufficient

Currently, 15.8% of people with common mental conditions access psychological therapies each year. However, even with the Government’s proposals this will only increase to 25% by 2020/21 (HEE, 2017). This is still an unacceptable figure
and one that is emphasised by the UK Council for Psychotherapy (UKCP), who said the announcement falls far short of what is needed to offset the growing demand for NHS mental health services.

According to UKCP Chair Martin Pollecoff: ‘To meet even existing demand, the Government should take advantage of the vast existing workforce of therapists. UKCP alone has more than 8000 highly qualified trained psychotherapists from different backgrounds, and many of them have medical experience’ (UKCP, 2017).

Origin of investment misleading

This is not the first time the introduction of £1 billion for mental health services has been proposed. In 2016, then Prime Minister David Cameron announced almost £1 billion of investment as part of a ‘revolution’ of mental health treatment (Prime Minister’s Office et al, 2016). This commitment from the Government sounds impressive, but has to be considered in the context of cash terms rise in the NHS budget generally. The Government has pledged to increase NHS spending in England to £120 billion by 2020/21
(HM Treasury, 2015). For mental health spending to grow at the same rate as the rest of the NHS, around 11.9% of the extra funding given to NHS England needs to be spent on mental health (Full Fact, 2016). This works out at roughly £2.2 billion. This figure far exceeds the £1.4 billion pledged in the most recent announcement and clearly represents a slower rise in spending than other parts of the NHS.

Simply not good enough

At first glance, the Government’s proposals appear to be the desperately needed boost to mental health services, which should be welcomed. However, the explanations of how additional posts will be funded or the recruitment issues overcome does not add up and are simply not good enough.

The Government has sugar-coated the amount of investment pledged and the figure still falls far below what is needed for mental health. It therefore comes as no surprise that Labour’s Shadow Minister for Mental Health, Barbara Keeley MP, said the workforce plan: ‘offers little hope to those working in the sector faced with mounting workloads, low pay and poor morale’ (The Labour Party, 2017).

References

British Medical Association (2017) BMA responds to Department of Health mental health workforce plans. BMA, London. https://tinyurl.com/ybtgxye8 (accessed 29 August 2017)

Department of Health (2017) Thousands of new roles to be created in mental health workforce plan. DH, London. https://tinyurl.com/y9akdjdr (accessed 31 August 2017)

Full Fact (2016) Unanswered questions on “extra £1 billion” for mental health. Full Fact, London. https://tinyurl.com/y7oyy8qc (accessed 1 September 2017)

Health Education England (2017) Stepping forward to 2020/21: The mental health workforce plan for England. HEE, Leeds. https://tinyurl.com/ycebebna (accessed 25 August 2017)

HM Treasury (2015) Spending Review and Autumn Statement 2015. The Stationery Office, London

The Labour Party (2017) Tory Government promising jam tomorrow when action is needed today to tackle the staffing crisis in mental health – Keeley. The Labour Party, Newcastle upon Tyne. https://tinyurl.com/y7db35pf (accessed 29 August 2017)

Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. NHS England, Leeds. https://tinyurl.com/gvc4or3 (accessed 25 August 2017)

NHS Employers (2017) NHS Employers welcomes plan to prioritise mental health services. https://tinyurl. com/ydg8h3ca (accessed 29 August 2017)

Prime Minister’s Office, 10 Down-ing Street, Department of Health, NHS England, The Rt Hon David Cameron, The Rt Hon Jeremy Hunt MP (2016) Prime Minister pledges a revolution in mental health treatment. Department of Health, London. https://tinyurl.com/z69jcpc (accessed 1 September 2017)

Royal College of Psychiatrists (2017) RCPsych response to HEE’s Mental Health Workforce Plan. RCPsych, London. https://tinyurl.com/yc2p93k8 (accessed 25 August 2017)

Royal College of Nursing (2017) RCN responds to Mental Health Workforce Plan. RCN, London. https://tinyurl.com/yavm3ulq (accessed 25 August 2017)

Royal College of Occupational Therapists (2017) Royal College of Occupational Therapists welcomes an expansion in the mental health workforce. RCOT, London. https://tinyurl.com/ycl9bss2 (accessed 25 August 2017)

UK Council for Psychotherapy (2017) We urge the Government to use existing therapist workforce to plug treatment gap. UKCP, London. https://tinyurl.com/ydfojrpk (accessed 29 August 2017)

Taken from British Journal of Mental Health Nursing, published September 2017.

Ensuring the district nursing role does not die out

Adobe Spark (2)Recent figures published by the Welsh Government have revealed a 42% reduction in the number of district nurses in Wales between 2009 and 2015 (BBC News, 2016). The number of district nurses has fallen from 712 in 2009 to 412 in 2015, with six of the seven health boards in Wales reporting a reduction.

This follows trends seen in England in recent years, which has reported a 47% reduction in the number of qualified district nursing staff in the past decade (Royal College of Nursing (RCN), 2014). Frequent figures such as these have resulted in a warning from the RCN that district nurses are ‘critically endangered’ and face possible extinction by the end of 2025 (RCN, 2014). Consequently, it has called on the Government to fulfil its commitment to increase the number of community staff to 10000 by 2020.

Origins of district nursing

The district nursing role originated in 1859, when a wealthy Liverpool merchant, William Rathbone, employed a private hospital-trained nurse to care for his dying wife. He was struck by ‘the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided.’ Following the death of his wife, Rathbone set up a training home in Liverpool to give nurses the skills necessary to treat patients in the home.

The title came from the fact that Liverpool was split into 18 districts based on the parish system, so the nurses became known as ‘district nurses’.

There is little research, but a publication from the Department of Health revealed that more than 2.6 million people receive care from district nurses each year, in England and Wales alone, according to statistics gathered nationally (Department of Health, 2004). It is anticipated that this number will only increase.

Due to the increasing elderly population and number of people with long-term conditions, district nurses make a notable contribution to the NHS. Having specially qualified staff who are trained to deliver care to patients in their own homes, should reduce pressures on GP surgeries and emergency departments. However, the shortage of district nurses means many feel they are being pushed to breaking point. Reports of regular additional hours, activities left undone due to lack of time and a desire to leave the job are not uncommon.

The RCN have said the reduced numbers of district nurses has placed extra pressure on GP surgeries and emergency departments. Increases in caseloads from 30 patients to up to 150 means contact time is kept to an absolute minimum. This results in patients not receiving the appropriate care they need and therefore feeling they require further consultation by their GP or at the emergency department.

The future vision of district nurses

In 2009, The Queen’s Nursing Institute (QNI) published its 2020 Vision of the future of district nursing (QNI, 2009). It marked the 150 year anniversary of district nurses and highlighted their role in health care. Fundamentally, the principles of district nursing have changed little in 150 years and consist of ‘better care, closer to home’, ‘patient choice’, ‘integrated care’, and ‘co-production’ (QNI, 2009). As a specialism, district nurses are ‘practitioners, partners and leaders’ of care in the home (QNI, 2009).

Some of the issues identified in the QNI report surrounding district nurses included: ‘loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education’ (QNI, 2009).

It is important to highlight that there is a notable difference between nursing found in clinics, surgeries and other areas of primary care; and that found in patients’ homes. It is for this reason that the district nursing role remains an important part of the NHS.

The British Journal of Community Nursing and the QNI carried out a survey in 2008, gathering information and views from district nurses in England, Wales and Northern Ireland about the state of their specialism. The survey found that 13% of respondents’ employing organisations no longer use the title ‘district nurse’ at all. It also revealed that in those organisations that still use the title, more than 30% do not limit its use to those with a district nurse qualification (QNI, 2009). In some cases, the title was given to team leaders or case managers, with or without the qualification. Additionally, the survey revealed that only 48% of employing organisations continue to require district nursing team leaders to have the district nursing specialist practitioner qualification. Another 19%, who did at the time the report was published, plan to discontinue this requirement.

A follow-up report from the QNI published 5 years after the 2020 Vision, revealed an increase in the level of confusion about job titles, qualifications and roles concerning district nurses (QNI, 2014). As a result, one of the key recommendations of the the report was for a renewed investment in the district nursing specialist practitioner qualification.

Focus surrounding qualifications for district nurses was raised at the most recent RCN Congress, which passed a resolution calling on RCN council to lobby for all district nurse caseload holders to have the relevant specialist practitioner qualification (Ford, 2016). This arose amid concerns over the future of the district nursing role and its protected title. The Forum called for a practitioner who is ‘equipped with skills to manage a role that is highly complex and requires skills in negotiating, coaching, teaching and effective team management’ (Ford, 2016).

The current climate

The situation surrounding the place and role of district nurses within the NHS has gradually changed over the years. For example, it is no longer the sole role to be found delivering nursing care in the home as there are now a multitude of community roles working at different levels. The issue with this is that the meaning attributed to the district nurses’ unique title has eroded somewhat. As mentioned, some employers are using the title without the accompanying specialist qualification, further muddying the waters. District nurses are excellently placed to offer leadership over other health professionals in the home. However, if they have not received adequate training they will struggle to have the strong leadership skills required.

Within Simon Stevens’ Five Year Forward View he called for the introduction of a new care model known as Multispecialty Community Providers. One of the benefits of this model is to allow for the expansion of primary care leadership to include nurses and other community-based professionals. This new way of delivering care and ability to offer a wider scope of services is made possible by allowing the formation of extended group practices as federations, networks or single organisations.

Conclusions

District nurses offer a much-valued service to the NHS through their ability to treat large numbers of people at home, allowing patients to avoid having to go to hospital if they receive the appropriate level of care first-time around. However, this is only possible if the number of district nurses does not continue to fall. The reality is that those still in the role are under increasing pressure, as they find their workloads ever-increasing. The Government must fulfil its commitment to increase the number of community staff, and in particular, the number of district nurses.

Now, more than ever, is the time to reinstate the district nurse.

References

BBC News (2016) Royal College of Nursing concern over fall in district nurses in Wales. BBC News. http://www.bbc.co.uk/news/uk-wales-36828072 (accessed 17 August 2016)

Department of Health (2004) Patient Care in the Community: NHS District Nursing Summary Information for 2003–04, England. The Stationery Office, London. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4092113.pdf (accessed 17 August 2016)

Ford S (2016) All district nurses ‘should have specialist qualification’. Nursing Times. http://www.nursingtimes.net/news/community/all-district-nurses-should-have-specialist-qualification/7005789.fullarticle (accessed 18 August2016)

Health Education England (2015) District Nursing and General Practice Nursing Service Education and Career Framework. HEE, London. https://hee.nhs.uk/sites/default/files/documents/District%20nursing%20and%20GP%20practice%20nursing%20framework_0.pdf (accessed 17 August 2016)

Royal College of Nursing (2014) District nurses face ‘extinction’ in 2025. RCN, London. https://www2.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025 (accessed 17 August 2016)

The Queen’s Nursing Institute (2009) 2020 Vision: Focusing on the Future of District Nursing. QNI, London. http://www.qni.org.uk/docs/2020_Vision.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute (2014) 2020 Vision Five Years On: Reassessing the Future of District Nursing. http://www.qni.org.uk/docs/2020_Vision_Five_Years_On_Web1.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute, NHS England (2014) Developing a National District Nursing Workforce Planning Framework: A Report Commissioned by NHS England. https://www.england.nhs.uk/wp-content/uploads/2014/05/dn-wfp-report-0414.pdf (accessed 15 August 2016)

Taken from British Journal of Community Nursing, published 2 September 2016.