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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Whole system change needed in gender identity services

My Post (5)Gender identity services in the NHS are failing to meet the needs of patients. Huge delays in treatment are forcing many to go private or abroad, while a lack of funding and suitably trained staff means patients are not receiving adequate care.

Gender dysphoria is a condition whereby a person experiences discomfort or distress because there is a mismatch between their biological sex and their gender identity (NHS Choices, 2016). Figures estimate there are 650 000 people in the UK living with gender dysphoria, which is equal to 1% of the population (Women and Equalities Committee, 2016). This is expected to rise as society’s increasing tolerance and acceptance of transgenderism has encouraged more people to come forward and seek medical help.

In the UK, transgender people’s health needs regarding gender dysphoria are being met at specialised NHS gender identity clinics or through private care. At present, all GPs in England, Northern Ireland and Scotland may refer their patients directly to a gender identity clinic, and do not need to refer them to a mental health service for assessment beforehand. In Wales, however, GPs have to refer first to a local psychiatrist, who assesses the patient and can recommend they are referred for assessment and treatment at a gender identity clinic (General Medical Council (GMC), 2017).

Unacceptable waiting times
Waiting times for people with gender dysphoria before their first appointment at an NHS gender identity clinic are unacceptable, as are the times for subsequent gender reassignment surgery, should it be wanted. This, in turn, has a massive impact on the health and wellbeing of trans patients. According to the GMC, the risk of self-harm and suicide for trans people is much greater than in the general population, and any delays in accessing medical care can substantially increase these risks (GMC, 2017).

Under the NHS Constitution, patients are legally entitled to have their first appointment at a specialist service within 18 weeks of referral (Department of Health, 2015). However, due to increased demand, some transgender patients have found themselves waiting up to 4 years for an appointment (Lyons, 2016). Remarkably, it was only in January 2015 that the NHS accepted that the 18-week principle applies to gender identity services too (Women and Equalities Committee, 2016).

It is because of these long waiting times that many trans people are turning to private care—but this does not come cheap. Initial appointments can cost between £220 and £280, and tend to cover assessment, diagnosis and recommendations. It is generally after two appointments that hormone therapy is started.

The cost of gender reassignment surgery varies considerably and prices range from £10 000 to £20 000. In desperation, many are turning to far-flung destinations, such as Thailand, to have this surgery.

Things need to change
In an attempt to meet the increased demand on gender identity services, NHS England invested an additional £6.5 million in this area this year. It is hoped this will go some way to reducing waiting times. However, despite increased funding, there is no detracting from the stark truth that the NHS is letting transgender people down. Notably, according to a Government report on transgender equality, the NHS is ‘failing in its legal duty under the Equality Act’ (Women and Equalities Committee, 2016).

A lack of knowledge and understanding among many clinicians and staff within the NHS has meant transgender people all too often encounter significant problems, whether through prejudice or the provision of inappropriate care. Additionally, other commonly cited concerns include too much variation in clinical protocols, confusion about what is available in the NHS, and inequitable access arrangements (Women and Equalities Committee, 2016).

Following this report, NHS England asked its Clinical Reference Group for Gender Identity to make recommendations on new service specifications for these specialist clinics. This led to a 12-week public consultation on proposals for new service specifications that, if adopted, will describe how specialised gender identity services for adults will be commissioned and delivered in the future within England. The final decisions will be made at the end of autumn 2017.

Relationship between public and private services
Among the changes set out in the consultation include a proposal that only designated specialist gender identity clinics will be able to refer individuals for reassignment surgery in the NHS. This would mean other NHS professionals or private clinics would not be able to make the referrals. The decision was made because it is felt the multidisciplinary teams of gender identity clinics are best placed to consider an individual’s suitability for surgery in the context of the relevant medical, psychological, emotional and social issues (NHS England, 2017). They are also able to accurately gauge the likely range of risks in each case.

Unfortunately this means patients would be unable to begin down the private pathway of care for an initial assessment and diagnosis, before moving to the NHS for gender reassignment surgery. Though this would go some way to diverting pressures on NHS services, it could be argued that boundaries of care between private and public could be blurred, making it difficulty to ensure safety and quality of care. Equally, referrals to an NHS gender clinic would have to come through an NHS pathway.

A gender identity specialism is needed
The lack of suitably trained staff to take on specialist roles being created in nursing, medicine, psychology and other professions is one of the key reasons for unprecedented demand on gender identity services. There are under a dozen people in the UK working both privately and in the NHS who can carry out vaginoplasty or phalloplasty operations (Parkins, 2016).

With the above in mind, there have been discussions with Health Education England, the GMC and the Royal College of Physicians about the development of a gender identity specialism, supported by appropriate curricula and recognition. It is evident that this is sorely needed; however, even at a grassroots level, training for GPs is insufficient, consisting of two online educational modules on gender variance on the Royal College of General Practitioners’ website. Without a proper understanding of this patient population, health services cannot begin to address their needs.

Conclusion
While momentum for change is gathering and the Government is beginning to listen, anything short of a whole system change in gender identity services would be insufficient. Waiting times are the most pressing concern that need to be addressed, with demand and capacity out of balance. Quality indicators are needed to assess quality and benchmark providers; a better interface with primary care services is essential; and increased understanding and knowledge across all health services is paramount. Transgender people have just as much right to care as anyone else, and health services and professionals cannot let them down.

References

Department of Health. NHS Constitution for England. 2015. http://tinyurl.com/d7sa3wq (accessed 23 October 2017)

General Medical Council. Good medical practice. Trans healthcare. Treatment pathways. 2017. http://tinyurl.com/grugw8z (accessed 19 October 2017)

Lyons K. Gender identity clinic services under strain as referral rates soar. 2016. http://tinyurl.com/hcb9uzz (accessed 19 October 2017)

NHS Choices. Gender dysphoria. 2016. http://tinyurl.com/ybt7rbj7 (accessed 19 October 2017)

NHS England. Guide to consultation: specialised gender identity services for adults. 2017. http://tinyurl.com/ydg3pfmh (accessed 19 October 2017)

Parkins K. Meet the gender reassignment surgeons: ‘Demand is going through the roof’. 2016. http://tinyurl.com/hdblcpg (accessed 19 October 2017)

Women and Equalities Committee. Transgender equality: first report of session 2015–16. 2016. http://tinyurl.com/y8sftc2h (accessed 19 October 2017)

Taken from British Journal of Cardiac Nursing, published November 2017.

How will the election affect the NHS?

The outcome of the general election marks the first Conservative majority Government for 18 years. Despite polls anticipating results between Labour and the Conservatives to be tight, David Cameron’s party achieved a convincing victory. So what effect will a Conservative majority Commons have on the NHS?

Health and social care was one of the key issues addressed during the 2015 general election campaign, and the Conservative Party have committed to spend at least an additional £8 billion on the NHS over and above inflation by 2020 (The Conservative Party, 2015). This is in line with the amount outlined by Simon Stevens in the Five Year Forward View (NHS England et al, 2015) as being required if the NHS is to be sustainable. However, the Conservatives have not yet indicated where this money will come from or how much will come each year.

The Conservatives plan to continue to strive for a truly 7-day NHS, and aim to give all patients access to a GP from 8:00 am to 8:00 pm, 7 days a week by 2020 (The Conservative Party, 2015). They have guaranteed that everyone over 75 years will get a same day appointment if they need one, and have said they will train and retain an extra 5 000 GPs (The Conservative Party, 2015). However, analysis published by the Royal College of General Practitioners suggests that under current systems, patients will have to wait until 2034 for the proposed additional GPs (Rimmer, 2015). The College has estimated that 8 000 more GPs will be needed in England by 2020 to keep up with patient demand, and so an emergency package of measures is needed if this is to be realised (Rimmer, 2015).

Other priorities for the Conservatives include equal priority for the treatment of mental conditions and the need to integrate health and social care systems by joining up services between homes, clinics and hospitals (The Conservative Party, 2015).

The impact for ambulance services of 5 years under the Tories is unclear. However, it is likely that the gradual shift in focus to treat people at home rather than in A&E will see an enhanced role for paramedics. That being said, it will not be easy. While paramedics are well placed to provide additional health services, February saw the profession being added to the shortage occupation list for the first time, as increased pressures brought on by longer hours and growing stress levels have led to many looking for alternative lines of work.

NHS Providers chief executive, Chris Hopson, has argued that until performances and finances are stabilised the NHS cannot transform (Hopson, 2015). Going forward this will undoubtedly be the challenge for the Conservative Government. By addressing these factors as a priority, only then can patient quality of care be ensured.

References

The Conservative Party (2015) Strong leadership. A clear economic plan. A brighter, more secure future. The Conservative Party Manifesto 2015. http://tinyurl.com/q82h3g6 (accessed 1 June 2015)

Hopson C (2015) The new health secretary will face an uphill battle. HSJ. http://tinyurl.com/ovw3j7a (accessed 1 June 2015)

NHS England, Public Health England, Health Education England, Monitor, Care Quality Commission, NHS Trust Development Authority (2014) Five Year Forward View. http://tinyurl.com/kcjenmc (accessed 1 December 2014)

Rimmer A (2015) It will take up to 31 years to deliver number of GPs promised by political parties, says RCGP. BMJ 350: h2472. doi: 10.1136/bmj.h2472

Taken from Journal of Paramedic Practice, published 5 June 2015.