Nurse ‘graduate guarantee’: supply solution or short-term fix?

In late summer, the government announced a ‘graduate guarantee’ that promised a job for every newly qualified nurse or midwife in England.

The Department of Health and Social Care (DHSC’s) initiative is aimed at fixing an immediate problem – that these new graduates can struggle to find a job. But it also raises a much bigger question: what are the roles and limitations of government and the NHS in securing the future supply of nurses? 

The immediate concern

Some newly graduated nurses and midwives have not been able to find a first NHS job, in part because of local recruitment freezes in various NHS trusts. There are up to three times more new nurse graduates than vacancies in some areas of the NHS and overall there are 4,000 more graduates in England than vacancies. This is not a good look for an employer aiming to encourage future recruitment to the profession.

The DHSC was quick to respond with the Graduate Guarantee, which states that every new nurse graduate ‘will have the opportunity to apply to join the health and social care workforce’.  At its core, the guarantee is about repurposing local funds previously earmarked for other vacant posts to create ‘time-limited’ registered nursing posts tailored to the new graduates. 

The impact of this initiative will become evident over the next few months, but clearly it is a rapid, top-down policy response, which is explicitly time limited and without significant additional funding. 

Unless it is matched by a commitment to retain these new graduates beyond the time-limited guarantee, it risks some not receiving the necessary support to integrate and thrive in a new and unfamiliar work environment. This requires structured supervision, mentoring and job experience in their early months at work, as exemplified by the Flying Start NHS programme in Scotland. The time-limited nature of the posts also risks nurses being unemployed when the period ends, even with support.

New graduate nurse supply: securing the future 

The current mismatch between new nurse graduate output and job availability raises another significant question: how can the NHS support enough new nurses to meet projected demand?

Firstly, this year’s mismatch is not unique. It has happened before and will happen again, given policy and planning disconnects between undergraduate nurse intakes and nurse job availability.  

In England, there is no direct link between planning projections for how many nurses we’ll need and decisions on how many new nurses to educate, and there is no direct influence on where they decide to work. The number of students entering undergraduate nurse education is determined firstly by the number of suitable applicants, and secondly – and more importantly – by university capacity and decisions on intakes.

Student nurse application numbers in England have been dropping in recent years, and the total numbers accepted by universities onto undergraduate courses have ‘stagnated’. There is particular concern about the low numbers completing mental health and learning disabilities undergraduate courses.

Those that complete undergraduate courses are the main supply of new nurses coming directly from domestic training.  There will not have been an explicit ‘guarantee’ to these students of an NHS nurse job on completion of undergraduate education. At times of nurse shortages and significant job vacancies, as in recent years, this has not been a problem for individual graduate nurses, who usually have had good job prospects and multiple opportunities.

But this year there is tight funding and a vacancy freeze in parts of the NHS. These new nurses are graduating into a world that has more limited job opportunities than when they entered their training 3 years ago. And their job-seeking difficulties become more pronounced if they have limited scope to move locations for any available vacancies.

What this means for the 10-Year Health Plan

This raises important implications for the new NHS workforce plan in England, which is in development to support the implementation of the 10-Year Health Plan. 

There are three sources for the future supply of new nurses: domestic undergraduate nurse education, the graduate nurse apprenticeship route, and international recruitment. The 10-year plan makes a commitment to actively reduce the level of NHS reliance on international recruitment to 10%. In terms of new nurse registrants, this figure has been exceeded – often by two- or threefold – every year since 1990 and topped out at almost 50% in 2022/23 (see charts below). 

International recruitment of registered nurses is a relatively quicker method of increasing supply than waiting 3 years for student nurse intakes to graduate. It can also be more flexible numerically than domestic training because there is scope to manage the size of the international inflow through immigration and professional regulation policies. It is striking to note how the international part of the annual intake (red in the charts above) has ebbed and flowed across the years.

If England is to switch to greater reliance on the supply of home-trained new nurses, this means increasing undergraduate student nurse numbers and/or intakes to nurse degree apprenticeships. The latter is the newer route, and holds promise, but has uncertain funding.

Just as importantly, it must also ensure that relatively more of this increased supply enters the labour market in regions with higher vacancies, and that this workforce is job-ready with the skills and qualifications currently in critical shortage – on learning disabilities, mental health and community health.

The new workforce plan will need to consider how best to achieve this domestic pivot. It looks to be a major challenge, given the current lack of direct control over undergraduate nurse numbers and tight funding for graduate apprenticeships. At best, the Graduate Guarantee is a short-term fix using current resources. The workforce plan will have to take a 10-year view on how to increase resources to guarantee more nurse graduates.